Job Summary
Under the supervision of the Program Director, or Social Work Supervisor, The PACE Masters-level Social Worker provides direct social work case management services for participants enrolled in PACE. The Social Worker functions as a member of the interdisciplinary team and works with participants to increase independence and community integration through a model of self-determination. Additionally, this role will liaise between participants, members of participants support network, and the interdisciplinary team.
Responsibilities

• Conducts initial psychosocial assessments on prospective program participants and consults with family or other support system members as needed.
• Develops clear and timely written social service care plans and implements same for assigned caseload.
• Periodically reviews social service care plans as needed or required, and revises as appropriate.
• Maintains regular attendance at, and participation in, interdisciplinary team meetings; collaborates on care planning and service allocation decisions.
• Assists families with problem solving around care-giving issues and serves as the facilitator of family and participant meetings as needed.
• Provides crisis intervention, and advocacy as needed for assigned caseload.
• Provides supportive counseling to participants and families as needed.
• Develops and facilitates support groups.
• In conjunction with the interdisciplinary team, coordinates discharge planning for participants returning home from hospitals, nursing homes, adult family homes, or group homes; coordinates admissions to group homes, adult family homes, and nursing homes.
• Assists participants with housing issues.
• Maintains current, well-organized case management records in accordance with social work and Electronic Medical Record (EMR) documentation standards.
• Assists participants with money management as needed.
• Assists financial eligibility staff or county and state agencies in resolving financial eligibility related issues for assigned caseload as needed.
• Attends conferences and seminars to maintain State Social Worker certification, and to stay informed of developing trends in geriatric, developmentally or physically disabled social work practice.
• Develops knowledge of community networks and resources for elderly, developmental or physically disabled population of diverse ethnic and cultural backgrounds and forms collaborative relationships with same. Provides information to participants to assist in establishing and maintaining community links.
• Advocates on behalf of participants for benefits and services through government and community agencies.
• Assists participants in completing advance directives and guardianship paperwork.
• Provides bereavement follow up as needed.
• Facilitates participant enrollment and disenrollment from the program.
• Conducts home visits and home assessments as needed.
• Provides Social Work services to assigned caseload, based on program needs across sites.
• Participates in cross-site Social Work Department meetings, other site-based meetings and agency-wide committees.
• Protects privacy and maintains confidentiality of employee, participant, and sensitive agency information.
• Supports High Desert PACE mission and values.
• 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.
• Performs related duties as assigned; including providing temporary coverage for other sites as needed and assigned by your supervisor.
• Completes other projects and duties as assigned.

Skills and Abilities

• Strong organizational skills demonstrated by the ability to effectively and efficiently prioritize and process multiple tasks.
• Clear understanding of interdisciplinary team care planning and decision-making processes; proven effective team contributor.
• Basic computer skills; familiar with electronic communication, word processing and data entry.
• Demonstrates necessary skills and knowledge as outlined in attached position-specific Competency Assessment Profile.
• 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
• Interpersonal skills include: Initiative and resourcefulness.
• Use of discretion, tact, patience and good judgment.
• Empathetic and compassionate attitude in caring for the elderly.

Education & Training

• Masters degree in social work and current California Certification required.
• A minimum total of one year of personal, clinical/internship, and or employment experience providing care or services for a frail or elderly population, and or a developmentally or physically disabled population required.
• One to two years case management experience preferred.
• Valid BLS certification from approved American Health Association provider required upon hire.