Job Description

Certification Details

• BLS
• Relevant State Licensure

Job Details

• Responsible for managing a caseload of participants working closely with the WelbeHealth Interdisciplinary Team (IDT).
• Deliver standard social work services such as psychosocial assessments, care planning, counseling, and case management.
• Function as a liaison between participants, family members, IDT, and other support network members.
• Collaborate effectively with colleagues and stakeholders to promote WelbeHealth values, team culture, and mission.
• Conduct social work assessments to determine psychosocial needs, preferences, and goals of participants.
• Participate in IDT meetings to develop participant care plans.
• Deliver and document social work interventions including arranging resources, assisting with care transitions, providing counseling and case management.
• Support smooth care transitions between settings (hospitals, skilled nursing facilities, home, etc.) with PACE Physician and IDT.
• Update IDT promptly of any changes in participants’ condition or psychosocial status.
• Facilitate enrollment of prospective participants into the program in coordination with Intake team.
• Initiate, coordinate, and facilitate care conference meetings for care coordination among PACE IDT members, participants, and support network.
• Provide discharge planning when participants disenroll from the program.
• Provide educational in-services regarding psychosocial aspects of aging and related issues.
• Participate in end-of-life care coordination and support.
• Conduct home visits as necessary.
• Provide support with Medi-Cal and Medicare enrollments to benefits eligibility staff.
• Must have reliable transportation to travel to participants' homes within assigned territory.
• Act only within the scope of authority to perform.
• Complete all required documentation timely and accurately.
• Protect privacy and maintain confidentiality of company procedures and information.
• Follow WelbeHealth policies and procedures and participate in Quality Improvement activities, staff training, and meetings.
• Communicate regularly with Supervisor and team regarding workload and priorities.

Job Requirements

• Minimum of one year of experience with a frail or elderly population.
• Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and interdisciplinary team members.
• Experience coordinating and facilitating care conference meetings.
• Ability to facilitate problem-solving with challenging psychosocial and family situations.
• Highly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situations.
• Ability to work independently with minimal supervision.
• Demonstrated ability to prioritize in a fast-paced environment.
• Experience and competency working with people from diverse backgrounds and cultures.
• Commitment to unlocking the full potential of vulnerable seniors.
• Preferred: Experience supporting individuals with behavioral health and substance abuse issues.
• Must be legally authorized to perform in position location.
• An unlicensed Social Worker shall only provide social work services for which no license is required under Business and Professions Code section 4996.

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