Social Worker-PACE Program

Community health is about more than just vaccines and checkups.
It’s about giving people the resources they need to live their best lives.
At Neighborhood, this is our vision.
A community where everyone is healthy and happy.
We’re with you every step of the way, with the care you need for each of life’s chapters.
At Neighborhood, we are Better Together.
As a private, non-profit 501(C) (3) community health organization, we serve over 350k medical, dental, and behavioral health visits from more than 77k people annually.
We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.
We have been doing this since 1969 and it is our employees that make this mission a reality.
Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond.
If that sounds like an organization you want to be a part of, we would love to have you.
ROLE OVERVIEW and PURPOSE The Social Worker will manage a caseload of participants by providing a psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes of the PACE program at Neighborhood Healthcare (Neighborhood).
This role will collaborate with the interdisciplinary team to optimize the health status and quality of life of Neighborhood PACE participants.
Additionally, this role will liaise between participants, members of participants’ support network, and the interdisciplinary team.
RESPONSIBILITIES Works with the PACE Interdisciplinary Team (IDT) to conduct initial, semi-annual, unscheduled, and annual assessments Provides participant health status updates to appropriate staff in daily meetings Obtains extensive psychosocial history from participants and/or family members upon admission to program and intermittently at pre-enrollment Coordinates, schedules, and facilitates family conferences in conjunction with the PACE IDT to address levels of care, medication/treatment non-compliance, out-of-home placement, complex diagnoses, behavioral concerns and contracts, conditions of involuntary disenrollment, and alternative program options Develops and facilitates various group counseling topics designed to assist at-risk populations over the age of 55 with chronic health conditions Provides individual caregiver and family support counseling, as needed Coordinates with participants, family/caregivers, and primary care providers to complete advance life planning documents, assist with end-of-life planning, and provide educational resources Conducts independent risk and safety assessments at skilled nursing facilities, residential care facilities for the elderly, assisted living facilities with/without memory care units, hospitals, and in-home, as needed Screens and develops share of cost for out-of-home placements based on financial documentation from participants and family members Creates and executes supportive housing forms with care facilities and family members, Conducts intermittent and annual income reviews to update supportive housing forms and share of costs Schedules, coordinates, and accompanies participants and family members with transportation and admission to higher level of care to promote safety and continuity of care in cases of high acuity Implements hospice and palliative care services by providing referral documentation, coordination, education, and support to participants and families Communicates with hospitals/skilled nursing facilities and utilizes external medical records systems to coordinate tailored discharge planning for participants Assists with ongoing financial eligibility for participants, including Medi-cal recertifications, as needed Liaises effective connections and communications with other organizations in the eldercare field Provides support and education to staff members in areas of social, emotional, and cultural factors in the participant population, including how these factors relate to health, medical care, and the availability of social services in the community Schedules, coordinates, and conducts in-home visits and assessments independently and in conjunction with the PACE IDT, as needed Provides redirection and support for participants with behavioral needs during PACE Day Center attendance, utilization of PACE transportation, and use of other PACE services Refers participants and families to appropriate community agencies and facilities while acting as an advocate and liaison with such organizations Conducts discharge planning to promote continuity of care in the event of disenrollments Maintains federally compliant and timely documentation of institutionalizations, Adult Protection Service reports/follow-ups and consultations, community contacts, family conferences, assessments, and other case management notes in medical records Attends required staff meetings/trainings and voluntary professional development courses EDUCATION/EXPERIENCE Master’s degree in social work required CPR/First Aid Required One year experience working with frail or elderly populations required One year of social work experience preferred Experience working in a community-based setting or geriatric program preferred Bilingual (English/Spanish) preferred ADDITIONAL QUALIFICATIONS (Knowledge, Skills, and Abilities) Excellent verbal and written communication skills, including superior composition, typing and proofreading skills Ability to interpret a variety of instructions in written, oral, diagram, or schedule form Knowledgeable about and experience with counseling theories and techniques Knowledgeable about and experience with community resources for individuals and families Ability to establish and maintain good interpersonal relationships Ability to successfully manage multiple tasks simultaneously Excellent planning and organizational ability Ability to work as part of a team as well as independently Ability to work with highly confidential information in a professional and ethical manner Physical Requirements Ability to lift/carry 10 lbs/weight Ability to stand for long periods of time Neighborhood Healthcare requires employees to be fully vaccinated (including a booster dose) against COVID-1 and demonstrate proof of vaccination/booster upon hire or receive approval for an exemption based on a medical reason, disability, or religious belief.
Proof of booster dose will be contingent upon booster eligibility.
Pay range: $72K-$88K, depending on experience.