Job Details

Social Worker

The Social Worker provides direct case management services to participants. The primary role of the MSW is to assist participants and their families/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence. Under the supervision of Regional Social Work Manager with additional oversight from the Program Manager and support from the Social Work Lead (SWL) at the center, the MSW serves as an integral member of the Interdisciplinary team (IDT) providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families.

Duties/Responsibilities: Clinical Practices and Case Management

• Utilize independent judgment and discretion to provide case management to a panel of participants.
• Conduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.
• Partner with caregivers and support systems to develop care plans and deliver services.
• Identify risks and other psychosocial problems.
• Identify service needs of each participant; advocate, refer, coordinate and follow up in a timely fashion.
• Provide individual counseling.
• Facilitate family conferences.
• Reach out to the larger community to meet participants specific needs.
• Assess needs and complete discharge planning when a participant dis-enrolls from the program.
• Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.

Interdisciplinary Team Member Roles and Responsibilities

• Act as the main liaison between participants, caregivers, the team, and the community.
• Work with relevant departments such as Health Plan and other community agencies (e.g. RCFE, NF, DAAS)
• Adhere to all ethical and legal standards of social work practices.
• Comply with all policies & procedures, safety, and confidentiality requirements.
• Fulfill all documentation requirements in a timely and accurate manner.
• Actively participate in team meetings, advocate for the needs of participants and their caregivers, compromise differences among team members, support and carry out team plans.
• Incorporate the Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.
• Assist in the continuous quality improvement of social work services and the efficiency of systems.
• All other reasonably related duties as assigned.

Qualifications:

• Graduate of an accredited college with an MSW degree.
• Minimum one-year experience with the frail or elderly.
• Experience or ability in working with a diverse population.
• Experience working within the framework of an interdisciplinary team.
• Good interpersonal skills including the ability to work cooperatively on an interdisciplinary team.
• Highly organized, able to prioritize tasks and conduct thorough follow-up.
• Excellent written and verbal communication skills.
• Computer literate and basic knowledge of Microsoft Office.
• Bilingual ability may be required for specific assignments.
• Experience with electronic health record systems (preferred).
• Minimum one-year post MSW experience (preferred).
• Minimum one-year case management experience (preferred).
• Minimum one-year healthcare-related experience (preferred).