Overview

The Social Services Worker provides social services support, case management, serves as patient advocate, coordinates admissions, discharge planning, or bereavement support services for patients and families

Responsibilities

Collaborates with members of the PACE Interdisciplinary Team (IDT) to develop and implement participant plans of care
Assists the patient and the caregiver in identifying and utilizing community agencies or facilities, acting as a liaison with the organizations and advocating for participants to obtain services for which they are eligible
Develops and maintains working relationships with community agencies
Demonstrates the necessary knowledge and skills to provide care appropriate to the age, developmental level, spiritual and cultural needs of the patient served
Demonstrates the necessary knowledge to appropriately document patient information in PACE electronic health record
Provides patient care in compliance with Medicare, Medicaid and Dept. of Social Services guidelines and regulations to achieve optimal outcomes
Coordinates the resolution of patient and/or family concerns
Coordinates appropriate admissions and discharges in a timely and efficient manner
Demonstrates empathy and strong negotiation skills with patients and families when assessing transitional level of care needs
Provides support counseling to facilitate adjustment to illness, disability and death
Makes adequate preparation for case conferences by documenting information as required and discusses information with appropriate staff in a timely manner
Identifies need for evaluation or service by other team members, consultants, or community resources, and initiates appropriate referrals
Provides quality care to patients within framework of Medicare, Medicaid, and Dept. of Social Services guidelines
Assists participants and caregivers maintain eligibility for Medicaid and tracking eligibility renewals, along with assisting participants apply for social security disability and Medicare coverage as needed

Defines the patient/family problems based on assessment and develops short and long-term goals seeking optimum outcomes for the patients and families

Assists the clinical team with inpatient utilization review and discharge planning

Assists in the management of home-bound participant through regular visits and telephone contacts.

Assist participants who live (not by choice) in substandard housing to find better places to live

Participates in coordination of 24-hour care delivery system, Quality Assurance and Performance Improvement program, and family conferences, team meetings, committees, and work groups as required

Other duties as assigned

Qualifications