PACE Medical Social Worker

Schedule: Monday - Friday, 8:00am-5:00pm. This role can accommodate a hybrid work schedule, allowing you to work from home a few days each week. Days "in-office" may be a variety of our locations including; PACE Center, patient homes, facilities, hospitals. Territory for this role is Boulder County and SW Weld County.

No weekends, no nights, no on-call! Paid holidays!

JOB SUMMARY
The Medical Social Worker plans, organizes and implements social work services for PACE participants and families. Contributes the profession’s unique psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes that occur once participants begin the intake process and continue with ongoing services.

The Social Work 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 disenrollment procedures.

The Social Worker collaborates with the interdisciplinary team to ensure effective, efficient, and appropriate care to optimize the health status and quality of life of (PACE Program) 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.

SPECIFIC RESPONSIBILITIES

• Participates as a member of the interdisciplinary team (IDT). Maintains regular attendance at, and participates in all IDT meetings, communicating participant changes, collaborating on care planning decisions and coordination of 24-hour care delivery.
• Effectively identifies, responds to, recommends and/or resolves problems as they arise in collaboration with Manager, and IDT.
• Develops and maintains effective work relationships with participants, families, peers, co-workers, contracted entities and vendors, and the public.
• Demonstrates ability to coordinate multiple tasks simultaneously, and work independently with minimal supervision.
• Facilitates interdisciplinary team (IDT) process and ensures the implementation of the plan of care to meet client/family needs.
• Demonstrates a working knowledge of the stages and manifestations of change, loss and grief, including complicated grief.
• Recognizes signs and symptoms of psychiatric illnesses.
• Identifies physical, behavioral and affect changes to be reported to the attending physician or other team members.
• Establishes therapeutic relationships and maintains healthy interpersonal boundaries with clients and families from a variety of cultural and socioeconomic backgrounds.
• Identifies the need for consultation with other members of the interdisciplinary team or with experts in specialized areas of psychosocial practice.
• Pre enrollment initial psychosocial assessments (includes cognitive status, mental health, substance use history, behavioral concerns, family dynamics, and social supports.
• Assesses on an ongoing basis the psychosocial needs of clients and families based on emotional, environmental, financial, psychological, cognitive, social, cultural and health factors.
• Assesses the impact of altered health status on the ability of the client and family to employ adaptive coping mechanisms and manage the care of the client.
• Identifies existing and potential problems based on assessment data and the availability of support systems and community resources. Initiates referrals to appropriate community resources and assists the client and family in accessing resources.
• Demonstrates basic psychosocial assessment, planning, intervention, and evaluation skills.
• Follows policies and procedures in the assessment, planning, intervention, and evaluation of psychosocial services for clients and families.
• Performs social work duties within the social work scope of practice.
• Participates in the development of policies, procedures, clinical protocols, forms, and in-service programs as appropriate. Assures appropriate implementation of these items.
• Recognizes limitations on rights to confidentiality and self-determination in situations of mandatory reporting of abuse, neglect, and intent to do harm.
• Manages a caseload and delivers care in a cost-effective manner that demonstrates an understanding of program specific scope of care.
• Maintains social work competency evidenced by current licensure at Master or Clinical level by State Board.
• Facilitate, mediate, and document care conferences, family meetings, and care coordination meetings.
• Daily hospital calls for patients in hospital to discuss discharge planning; collaborates with hospital CM, ppt, caregivers, facilities, and IDT to ensure safe discharge
• Provides referrals and coordinate placement with contracted and non-contracted facilities (for respite, skilled, and long-term care placement. (Includes requesting transportation)
• Coordinate discharge from facility with facility SS, patient, caregivers, and IDT, (includes requesting transportation for discharge)
• Supports IDT in establishing behavior plans and APS reporting as needed
• Complete home visits or utilize telehealth when appropriate for reassessments and meetings

EDUCATION/EXPERIENCE

• Master’s Degree in Social Work
• Licensed as an LSW or LCSW preferred but not required.
• 2-3 years relevant experience working as an MSW.
• Experience working with individuals with mental health needs (Preferred).
• Experience working with the frail or elderly population (Preferred).
• Experience in team management, preferably in a geriatric care setting.
• Experience working within an Interdisciplinary Team Model.
• Experience with Electronic Medical Records (EMR).

REQ# 12622

Job Type: Full-time

Pay: $58,240.00 - $74,880.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Medical specialties:

• Geriatrics

Schedule:

• 8 hour shift
• Monday to Friday
• No nights
• No weekends

Work Location: Hybrid remote in Lafayette, CO 80026

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