BASIC PURPOSE & SCOPE:
Under the supervision of the Associate Program Director, the Social Worker is responsible for providing psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services and disenrollment processes that occur once participants begin the intake process and continues with ongoing services. Interventions could include individual participant contacts, appropriate collateral contacts, participant and family education, assessment and counseling, mobilizing resources, addressing mental health needs as they arise, ongoing case management, advocacy to ensure patient needs are addressed, and initiating disenrollment procedures. The Social Worker collaborates with the interdisciplinary team to ensure effective, efficient and appropriate care is provided in order to optimize the health status and quality of life of participants. The Social Worker is knowledgeable regarding social systems and institutions, and individual behavior, and can skillfully apply appropriate interventions to meet the needs of the participant and family.
- Establishes the initial plan of care for the patient and family in conjunction with the assigned RN and the attending physician, as authorized.
- Actively participates in interdisciplinary evaluation, assessment, and plan of care for all participants.
- Contributes professional Social Work prospective to these processes.
- Begins work for enrollment immediately after the initial psychosocial assessment; involves participant and family members in the planning process and ongoing care.
- Responds to identified needs of participants and their families in a clinically sound, therapeutic manner on an ongoing basis.
- Develops appropriate plans of care, based upon initial assessment information, consisting of living condition and/or situation, cultural influences and support systems to identify the member’s strengths and obstacles that affect their living condition into the community; utilizes information obtained by other caregivers, including appropriate data from the medical records, participant and interdisciplinary team.
- Reassesses participant at appropriate intervals according to PACE standards and the individualized needs of each participant.
- Provides counseling and crisis intervention, and addresses mental health needs as they arise.
- Provides linkages to community services, demonstrating a keen awareness of resources available and appropriateness to the needs of the participant family. Maintains current information related to community resources and federal and state guidelines.
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- Facilitates participant and family adjustment to lifestyle changes.
- Coordinates all matters pertaining to eligibility for PACE services, including verification or assistance with insurance coverage (including Medicare and Medicaid) and providing enrollment assistance. Educates and assesses participant’s and family’s understanding and ability to pay their Medicaid surplus payment as appropriate.
- Participates in meetings including, but not limited to, interdisciplinary team meetings, family meetings, staff meetings, in-service and training programs, rehab services meetings and Quality Improvement activities.
- Maintains flexibility in schedule and responds to unexpected emergencies and changes in workload in order to fulfill responsibilities.
- Effectively communicates and collaborates with all customers at all times.
- Responds to customer complaints and actively works to resolve issues/concerns.
- Maintains a positive working relationship with all customers. Consistently collaborates with and respects Total Senior Care team members, referral sources and outside agencies.
- Projects a professional image in appearance and action.
- Maintains self-control in difficult situations, listens to all concerns, and gathers information for problem resolution as necessary.
- Addresses financial issues if they arise, such as meeting with the participant, family contacts, and appropriate agencies to assist. As required by law and the Code of Ethics, the Social Worker contacts Adult Protective Services for investigation if a possible exploitation exists.
- In the event of nonparticipation on the part of the enrollee, talks to the enrollee and encourage attendance. If appropriate, informs team, especially medical staff, to determine need for participant attendance; informs supervisor and follows up.
- Completes medical chart documentation according to established documentation standards and in a timely manner.
- Meets deadlines for required for timely submission of information and reports.
- Consistently follows the Social Work Code of Ethics, treats all people with respect, maintains confidentiality and strives toward service excellence.
- Continues professional development though attendance at staff meetings and engaging in educational opportunities to maintain professional competence and licensure.
- Adheres to and reflects organizational values in daily work.
- Serves on agency committees as may be assigned.
- Maintains an obligation to report wrongdoing/violation of agency policies, applicable federal, state, and local laws, and rules and regulations pertaining to agency operations, to immediate supervisor or identified compliance officer.
- Completes all mandatory inservice education programs and completes any other additional inservice hours that are minimally required for the position.
The above examples of work may not be a complete statement of all assignments that may be inherent to the position. Other duties may be assigned as deemed necessary and appropriate by the Associate Program Director or Program Director.
- A master’s degree in social work obtained by successful completion of a prescribed course of study at a graduate school of social work accredited by the Council on Social Work Education and the Education Department, and current certification or license by the Education Department to practice social work in the State of New York.*
- One year of social work experience in a health care setting.*
- One year experience working with frail elders (may be concurrent with #2 above).
- Knowledge of PACE (Program of All-inclusive Care of the Elderly) regulations preferred.
- Demonstrated organizational and supervisory skills.
- Effective oral and written communication abilities.
- Acceptable driver’s license and automobile available for use with current insurance;
- Availability by, and use of, telephone at home/off-site;
- Other requirements (physical) – see attached.
* Consideration may be extended to a candidate in the event the master’s degree requirement is met but license not yet obtained (or pending) and/or experience requirement not met. In this case, supervision by the social work manager, a licensed social worker, will also include ongoing review of care plans and clinical documentation until satisfactory completion of all minimum requirements (licensure, experience) are met.