Master Social Worker

JOB SUMMARY

Assesses the psycho-social needs, provides of participants and advises the interdisciplinary team and his/her colleagues on the development and implementation of participant care plans. Provides social services support, case management, counseling and referrals to external agencies.

JOB RESPONSIBILITIES

Serves on the PACE interdisciplinary team (IDT). Performs assessments, scheduled reassessments and unscheduled reassessments of participant's history, personal and family circumstances, home environment, psycho-social status and cognition. Collaborates with other members of the IDT to develop participant plans of care. Refers participants to community agencies or facilities, acting as a liaison and advocating for participants to obtain services for which they are eligible. Communicates changes in participant status to interdisciplinary team members and notes changes in the plans of care. Helps participants cope with physical, social, emotional and psychological problems or disabilities. Helps participants understand and navigate Medical eligibility issues, tracking eligibility renewals and assisting with this process. Helps participants apply for social security disability and Medicare coverage as needed. Helps participants find better or alternative places to live, when appropriate. Helps participants maintain basic social supports so they remain safe, warm, and dry. Advises colleagues about ways to meet participants' social service needs. Develops and leads group sessions for cognitive stimulation and emotional health. Assists the clinical team with discharge planning and transitions of care, when necessary. Assists in the management of homebound participants and those at risk for caregiver stress through regular visits and telephone contact. Participates in family conferences, team meetings, committees and work groups as required. Participates in policy development and revision for the social work component of the program. Participates in the coordination ofa 24-hour care delivery system. Participates in the Quality Improvement program Completes all documentation in the medical record as required. Acts within the scope of his or her professional license. Assists MEOC with the completion and updating of the annual Uniform Assessment Instruments (UAI) on each participant, when possible. Other duties as assigned.

ESSENTIAL FUNCTIONS

Oral and written communication skills Interpersonal skills Computer skills Organizational skills Problem solving and conflict resolution skills Record keeping and reporting skills

SUPERVISORY RESPONSIBILITIES

None

QUALIFICATIONS

Master's Degree from an accredited School of Social Work. One or more years experience with a geriatric population. Valid driver's license and reliable transportation. Individual therapy, analytical thinking and problem solving skills. Must work well as part of a team. Medically cleared for communicable diseases with up-to-date immunizations before participant contact. Criminal history records check at hire. Drug screen at hire.

WORK SCHEDULE

Full Time. PACE Center operating hours are 8:30 a.m. to 4:30 p.m. Monday through Friday with occasional need for after-hours/weekend support.