Social Worker Lead - MSW

Social Worker Lead

The Social Worker Lead (SWL) provides direct case management services to On Lok participants and acts as the subject matter expert (SME) providing department leadership including administration, mentorship, and consultation at an appointed center. The primary role of the SWL is to assist participants and their family/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence.

Under the supervision of the Regional Social Work Manager, with additional oversight from the Center Director, the SWL serves as an integral member of the Interdisciplinary (IDT) team providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families.

Roles and responsibilities include:

• Utilize independent judgement and discretion to provide case management to a panel of participants
• Conduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.
• Partner with caregivers and support system to develop care plan and deliver services.
• Identify risks and other psychosocial problems.
• Identify service needs of each participant, advocate, refer, coordinate and follow up in a timely fashion.
• Provide individual counseling.
• Facilitate family conferences.
• Reach out to the larger community to meet participants' specific needs. Act as the main liaison between participants, caregivers, the team, and the community.
• Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.
• Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.
• May review and verify the findings of assessments conducted by non-MSW social workers.
• Act as the main liaison between participants, caregivers, the team, and the community.
• Work with relevant departments such as Health Plan and other community agencies e.g. RCFE, NF, DAAS (Department of Adult and Aging Services).
• Adhere to all ethical and legal standards of social work practices.
• Comply with all On Lok policies & procedures including but not limited to PACE, safety, and confidentiality requirements.
• Fulfill all documentation requirements in a timely and accurate manner.
• Actively participate in team meetings, advocate for the needs of participants and their caregivers, compromise differences among team members, support and carry out team plans.
• Incorporate the Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.

Lead responsibilities include:

• Is the subject matter expert (SME) of the electronic health record for the social work department.
• Assist in the review and update of department and IDT policies and procedures.
• Assist in the orientation and training for new Social Workers and Social Work Aides.
• Assist in overseeing competencies for social workers.
• Assist in developing, maintaining and facilitating relationships with other clinical disciplines and non-clinical staff in order to deliver quality participant care at appointed center.
• Assist with developing the social work education program.
• Primary point-person for social work issues at appointed center.
• Assist in providing support to Social Workers at appointed center.
• Assist in the continuous quality improvement of social work services and efficiency of systems.
• Actively participates and contributes to the Social Work Leadership Council (SWLC) activities.
• Assist with developing the social work continuing education program.
• Contribute additional clinical and/or workflow process perspective regarding participant care to Center Director in support of the MSW and…