Master Social Worker

JOB SUMMARY: Provides social services support, including participant screening, case management, counseling and referrals. JOB RESPONSIBILITIES:  Serves on the PACE interdisciplinary team (IDT).  Performs assessments, scheduled reassessments and unscheduled reassessments of participant’s history, personal and family circumstances, home environment, psycho-social status and cognition.  Collaborates with other members of the IDT to develop and implement participant plans of care.  Refers participants to community agencies or facilities, acting as a liaison with the organizations and advocating for participants to obtain services for which they are eligible.  Maintains written case management records and progress notes.  Communicates changes in participant status to interdisciplinary team members and notes changes in the plans of care.  Helps participants cope with physical, social, emotional and psychological problems or disabilities.  Helps potential participants address Medicaid long term care eligibility issues.  Helps potential participants understand nursing facility level of care criteria.  Helps participants maintain eligibility for Medicaid, tracking eligibility renewals from year to year.  Helps participants apply for social security disability and Medicare coverage as needed.  Helps participants who live (not by choice) in substandard housing to find better places to live.  Helps participants maintains basic social supports so they remain safe, warm and dry.  Develops and leads group sessions for cognitive stimulation and emotional health.  Assists the clinical team with inpatient utilization review and discharge planning.  Assists in the management of home-bound participants through regular visits and telephone contacts.  Visits participants in the home as needed.  Participates in family conferences, team meetings, committees and work groups as required.  Participates in policy development for the social work component of the program.  Participants in the Quality Assurance and Performance Improvement program.  Participates in the coordination of a 24-hour care delivery system.  Completes all documentation in the medical record as required.  Acts within the scope of his or her professional license. ESSENTIAL FUNCTIONS:  Oral and written communication skills  Interpersonal skills  Computer skills  Organizational skills  Problem solving skills  Record keeping and reporting skill