•TEMPORARY

ASSIGNMENT UNTIL 3/31/2027

•Position Summary The Social Worker (MSW) provides psychosocial expertise to the interdisciplinary team (IDT) throughout the PACE participant's evaluation, assessment, care planning, care coordination, and disenrollment processes. Supports the health, independence, safety, and quality of life of older adults and their families through person-centered social work interventions. Provides counseling, behavioral health support, case management, advocacy, resource coordination, and discharge planning. Collaborates with interdisciplinary team members to identify and address the unique physical, emotional, social, and behavioral health needs of PACE participants. Essential Job FunctionsPsychosocial Assessment & Care Planning Complete scheduled and unscheduled psychosocial assessments as required. Engage participants, families, and caregivers to identify health goals and expectations related to physical, medical, social, and emotional well-being. Identify risk factors affecting overall health and develop interventions to improve functioning and quality of life. Apply knowledge of lifespan development, family systems, behavioral health, and social determinants of health. Contribute the social work perspective to individualized care plans, addressing: Mental health stressors and psychiatric conditions. Family dynamics and trauma. Financial and food insecurity. Social isolation and natural supports. Physical safety concerns and other psychosocial needs. Interdisciplinary Team Collaboration Collaborate with IDT members to develop and implement participant care plans. Facilitate interdisciplinary team and care coordination meetings. Coordinate and facilitate family conferences in collaboration with the IDT. Participate in team meetings, staff meetings, Participant Advisory Committee meetings, and other assigned meetings. Provide professional recommendations to support participant health outcomes and quality of life. Counseling & Behavioral Health Develop and implement therapeutic support groups. Provide individual counseling and crisis intervention as appropriate. Identify and address behavioral health needs, including: Anxiety and depression. Maladaptive or risk-taking behaviors. Challenges with treatment adherence. Psychiatric illness and emotional distress. Provide a behavioral health perspective to ensure psychosocial barriers to health outcomes are addressed. Advocacy & Resource Coordination Maintain current knowledge of community resources and establish linkages to appropriate services. Advocate for participants and families by connecting them with: Housing and financial assistance. Food resources and legal aid. Mental health services and support groups. Other community-based resources. Provide participant and family education regarding available services and support. Advanced Care Planning & Transitions of Care Educate participants and families regarding advanced life planning. Coordinate completion of advanced life planning documents. Support participants and families with transitions of care and end-of-life matters. Participate in discharge planning and disenrollment processes. Complete disenrollment documentation and promote continuity of care. Participate in home visits as deemed necessary by the interdisciplinary team. Documentation & Professional Standards Complete timely and accurate documentation in the medical chart. Maintain confidentiality and comply with HIPAA requirements. Adhere to the Social Work Code of Ethics. Attend ongoing training, educational opportunities, and clinical supervision. Maintain professional competence and pursue continuous development. Perform other duties as assigned.

Minimum Qualifications:

Master's Degree in Social Work (MSW) from an accredited university is required. Minimum of 2 years of experience in case management, social advocacy, and/or mental health with the geriatric population. Fieldwork or internship experience may substitute for 1 year of required experience. Bilingual Spanish/English, Chinese/English, or another second language is strongly preferred. Valid BLS certification or higher, following American Heart Association (AHA) or American Red Cross guidelines, is required.

Skills & Abilities:

Strong oral and written communication skills. Excellent customer service and facilitation skills. Ability to organize, prioritize, and manage multiple responsibilities. Proficiency with Microsoft Office applications, including Word, Excel, and Access. Self-motivated, flexible, and adaptable. Thorough, detail-oriented, and able to follow through on assigned responsibilities. Ability to work semi-independently and collaboratively within an interdisciplinary team. Knowledge of DHCS and CMS requirements. Basic knowledge of HIPAA guidelines and requirements. Strong advocacy, counseling, problem-solving, and care coordination skills.

Pay:

$46.00 - $59.00 per hour

Education:

Master's (Required)

Experience:

Case management: 2 years (Preferred)

Social Advocacy:

2 years (Preferred) Mental health counseling: 2 years (Preferred)

Language:

Spanish (Preferred)

License/Certification:

BLS Certification (Required)

Work Location:

In person