Job Description

Job Description

Job Description

Job Purpose

The primary purpose of this role is to provide comprehensive psychosocial support to participants through conducting detailed assessments and developing individualized care plans that address their unique needs. This position involves delivering effective crisis intervention and serving as a key member of the interdisciplinary team (IDT), ensuring a collaborative approach to participant care. Additionally, the role includes assisting participants with various social needs, performing home visits to complete necessary assessments, and coordinating with other disciplines to ensure holistic and effective support. This position is essential in enhancing the overall well-being and quality of life for participants through integrated care and proactive support.

Duties and Responsibilities

• Conducts initial, semi-annual, and annual psychosocial assessments on participants, and consults with family or other support system members as needed.
• Develops clear and timely written social service care plans, and implements care plan for assigned caseload.
• Periodically reviews social service care plans as needed or required, and revises as appropriate.
• Maintains regular attendance at, and participation in, interdisciplinary team meetings; collaborates on care planning and service allocation decisions. Provides updates on participants changes to Region Functional Screener as needed/indicated.
• Assists families with problem solving around care-giving issues and serves as the facilitator of family and participants meetings as needed.
• Provides crisis intervention, and advocacy as needed for assigned caseload.
• Provides supportive counseling to participants and families as needed.
• Develops and facilitates support groups.
• In conjunction with the interdisciplinary team, coordinates discharge planning for participants returning home from hospitals, nursing homes, adult family homes, or group homes; coordinates admissions to group homes, adult family homes, and nursing homes.
• Assists participants with housing issues.
• Maintains current, well-organized case management records in accordance with social work and Electronic Medical Record (EMR) documentation standards.
• Assists financial eligibility staff or county and state agencies in resolving financial eligibility related issues for assigned caseload as needed.
• Attends conferences and seminars to maintain State Social Worker certification, and to stay informed of developing trends in geriatric, developmentally or physically disabled social work practice.
• Develops knowledge of community networks and resources for elderly, developmental or physically disabled population of diverse ethnic and cultural backgrounds, and forms collaborative relationships with same. Provides information to members to assist in establishing and maintaining community links.
• Advocates on behalf of participants for benefits and services through government and community agencies.
• Assists participants in completing advance directives and guardianship paperwork.
• Provides bereavement follow up as needed.
• Facilitates participants’ enrollment and disenrollment from the program.
• Conducts home visits and home assessments as needed.
• Participates in cross-site Social Work Department meetings, other site-based meetings and agency-wide committees.
• Performs related duties as assigned.

Qualifications

Education:

• Master’s degree in Social Work from an accredited University.
• Current BLS/First Aide preferred.

Experience :

• A minimum total of two years of experience in a clinical setting with frail or elderly population.

Skills and Knowledge :

• Effective written and oral communication skills.
• Demonstrated ability to problem solve and apply good judgment.
• Ability to function well independently.
• Ability to use or be trained in computer skills for the workplace.
• Demonstrates necessary skills and knowledge as outlined in attached position-specific Competency Assessment Profile.

Other:

• Requires physical strength to perform the job.
• Routine travel between PACE sites and in the community required.
• Requires valid driver’s license.

Physical Demands

• Must be able to remain in a stationary position 50% of the time.
• Ability to occasionally move about inside the office to access file cabinets, office machinery, etc.
• Able to operate a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer.
• Able to constantly position yourself to maintain files in file cabinets such as reaching with hands and arms, kneeling, crouching, etc.
• The ability to communicate, detect, converse with, discern, convey, express oneself, and exchange information is crucial for this role.

Direct Reports

PACE Center Manager

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