BASIC PURPOSE & SCOPE
Under the supervision of the Associate Program Director, the Social Worker is responsible for providing psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services and disenrollment processes that occur once participants begin the intake process and continues with ongoing services. Interventions could include individual participant contacts, appropriate collateral contacts, participant and family education, assessment and counseling, mobilizing resources, addressing mental health needs as they arise, ongoing case management, advocacy to ensure patient needs are addressed, and initiating disenrollment procedures. The Social Worker collaborates with the interdisciplinary team to ensure effective, efficient and appropriate care is provided in order to optimize the health status and quality of life of participants. The Social Worker is knowledgeable regarding social systems and institutions, and individual behavior, and can skillfully apply appropriate interventions to meet the needs of the participant and family.
- Establishes the initial plan of care
for the patient and family in conjunction with the assigned RN and the
attending physician, as authorized.
- Actively participates in interdisciplinary evaluation,
assessment, and plan of care for all participants.
- Contributes professional Social Work prospective to these
- Begins work for enrollment immediately after the initial
psychosocial assessment; involves participant and family members in the
planning process and ongoing care.
- Responds to identified needs of participants and their
families in a clinically sound, therapeutic manner on an ongoing basis.
- Develops appropriate plans of care, based upon initial
assessment information, consisting of living condition and/or situation,
cultural influences and support systems to identify the member’s strengths and obstacles
that affect their living condition into the community; utilizes information
obtained by other caregivers, including appropriate data from the medical
records, participant and interdisciplinary team.
- Reassesses participant at appropriate intervals according to
PACE standards and the individualized needs of each participant.
- Provides counseling and crisis intervention, and addresses
mental health needs as they arise.
- Provides linkages to community services, demonstrating a
keen awareness of resources available and appropriateness to the needs of the
participant family. Maintains current
information related to community resources and federal and state guidelines.
- Facilitates participant and family adjustment to lifestyle
- Coordinates all matters pertaining to eligibility for PACE
services, including verification or assistance with insurance coverage
(including Medicare and Medicaid) and providing enrollment assistance. Educates
and assesses participant’s and family’s understanding and ability to pay their
Medicaid surplus payment as appropriate.
- Participates in meetings including, but not limited to,
interdisciplinary team meetings, family meetings, staff meetings, in-service
and training programs, rehab services meetings and Quality Improvement
- Maintains flexibility in schedule and responds to unexpected
emergencies and changes in workload in order to fulfill responsibilities.
- Effectively communicates and collaborates with all customers
at all times.
- Responds to customer complaints and actively works to
- Maintains a positive working relationship with all
customers. Consistently collaborates
with and respects Total Senior Care team members, referral sources and outside
- Projects a professional image in appearance and action.
- Maintains self-control in difficult situations, listens to
all concerns, and gathers information for problem resolution as necessary.
- Addresses financial issues if they arise, such as meeting
with the participant, family contacts, and appropriate agencies to assist. As required by law and the Code of Ethics,
the Social Worker contacts Adult Protective Services for investigation if a
possible exploitation exists.
- In the event of nonparticipation on the part of the enrollee,
talks to the enrollee and encourage attendance.
If appropriate, informs team, especially medical staff, to determine
need for participant attendance; informs supervisor and follows up.
- Completes medical chart documentation according to
established documentation standards and in a timely manner.
- Meets deadlines for required for timely submission of
information and reports.
- Consistently follows the Social Work Code of Ethics, treats
all people with respect, maintains confidentiality and strives toward service
- Continues professional development though attendance at
staff meetings and engaging in educational opportunities to maintain
professional competence and licensure.
- Adheres to and reflects organizational values in daily work.
- Serves on agency committees as may be assigned.
- Maintains an obligation to report wrongdoing/violation of
agency policies, applicable federal, state, and local laws, and rules and
regulations pertaining to agency operations, to immediate supervisor or
identified compliance officer.
- Completes all mandatory inservice education programs and
completes any other additional inservice hours that are minimally required for
above examples of work may not be a complete statement of all assignments that
may be inherent to the position. Other
duties may be assigned as deemed necessary and appropriate by the Associate
Program Director or Program Director.
1. A Bachelor’s degree in social work obtained by successful completion of a prescribed course of study at a school of social work accredited by the Council on Social Work Education and the Education Department.
- One year of social work experience in
a health care setting.*
- One year experience working with frail
elders (may be concurrent with #2 above).
- Knowledge of PACE (Program of
All-inclusive Care of the Elderly) regulations preferred.
- Demonstrated organizational and
- Effective oral and written
driver’s license and automobile available for use with current insurance;
by, and use of, telephone at home/off-site;
- Other requirements (physical) – see attached.