Overview

About Fallon Health:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon delivers equitable, high-quality coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter, and LinkedIn.

About Summit ElderCare:

Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities.

Brief Summary of Purpose:

Functions as a member of the PACE Interdisciplinary Team and provides social work services and support to participants, families, and other caregivers. Provides direction to bachelors level social workers as assigned by Social Work Manager.

Responsibilities

Primary Job Responsibilities:

• Participates in the intake and evaluation process by conducting the initial social work assessment, administering MSQs, developing an intake summary and presenting the social work perspective to the Interdisciplinary Team.
• Assures that participants rights are reviewed during the intake process.
• Conducts reassessments at least semiannually and whenever there is a change in participant status or the participant /caregiver requests it.
• Develops and implements a social service plan of care for each participant and updates it based on the results of reassessments or on-going changes in status.
• Responsible for the maintenance of appropriate records and documentation in the medical record including at least the initial assessment, quarterly progress notes, significant changes and all participant-related interactions.
• Participates as a member of the Interdisciplinary Team at daily team meetings and care planning meetings.
• Assists team members to understand the social, emotional, cultural and psychosocial aspecst of participants’ situations.
• Acts as an advocate and liaison when counseling services are needed.
• Completes documentation and record-keeping related to disenrollment’s, deaths and permanent placement; distributes relevant notifications.
• Participates in the development, promotion and implementation of caregiver support groups or programs; leads or co-leads groups as necessary.
• Assists in managing referral telephone calls as needed.
• Implements program policies and procedures as directed. 
• Assists in the conversion of participants from community based Medicaid to long-term care Medicaid when necessary. Works collaboratively with the Operations Support Representative to assure appropriate access to Medicaid benefits.
• Pursues relevant professional development. Attends appropriate workshops and in-service activities to maintain current professional status.
• Consistently follows the Social Work Code of Ethics.
• Performs all duties in accordance with Fallon Health and Summit ElderCare policies and procedures.

Qualifications

Education:

Masters degree in Social Work

License:

Valid and unrestricted license to practice social work from the Board of Registration of Social Work of the Commonwealth of Massachusetts.

Valid Driver's License and reliable vehicle required.

Certification:

CPR and Alzheimer’s certification or willingness to be certified.

Experience:

At least two years experience in a Social Work capacity, preferably in a community setting, with a minimum of one year experience working with a frail or elderly population.

Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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