About the Role

The Social Worker plans, organizes and implements social work services to participants and their caregivers in accordance with Seen Health policies and all applicable regulations. As an integral member of an Interdisciplinary Team, the social worker performs psychosocial assessments, develops and implements plans of care, conducts counseling and case management, and facilitates communication between the participant, family, caregivers, PACE staff, and provider support network, as appropriate.

Responsibilities

• Conduct Social Work assessments to determine the psychosocial needs, preferences and goals of the participants and actively participate in IDT meetings to develop participant care plans.

• Deliver and document social work interventions as agreed upon in the participants’ care plans including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual as well as group counseling and case management.

• Completes initial assessments, re-assessments, and care plan updates for participants while continually evaluating the participants' social service needs and caregiver support needs.

• Participates in regularly scheduled behavioral management meetings with other mental health professionals.

• Work with the primary care physician and other members of the care team to guide smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home, etc.).

• Assists physician, or intermediate care provider, and other team members in understanding the significant social and emotional factors related to participant health problems.

• Acts as a resource to other team members and staff regarding topics such as dementia, difficult behaviors, and difficult personalities. Supports the IDT in establishing behavior management plans.

• Strive for continuous growth and development of cultural competency exhibiting an understanding, awareness, and respect for diversity.

• Maintains accurate and timely documentation and paperwork including participants’ electronic medical records according to policies and procedures.

• Provides referral support to community resources and participates in inter-agency coordination of care.

• Develops and maintains working relationships with community agencies, such as the Department of Social Services, psychiatric facilities, skilled nursing facilities, hospitals, social agencies, and may participate in hospital and/or SNF discharge planning.

• Initiate, coordinate and facilitate care conference meetings to ensure the highest level of care coordination among other care team members, participants, and other people within the participants’ support network (family, informal caregivers etc.).

• Responds to, investigates, and reports complaints of elder abuse.

• Maintains the confidentiality of all company procedures, results and information about participants, clients or families in conformance with Health Insurance Portability and Accountability (HIPAA) principles.

• Active contributor and change agent to continuously achieve quality care, participant experience and compliance goals.

• Proactively supports participant grievance and incident reporting processes.

• Completes timely discharge planning.

• Conducts home visits and travel to hospital facilities and/or other community agency, as needed.

• Participate in state and federal audit preparation activities.

• Performs related duties as assigned.

Qualifications

• Master’s degree from a school of social work accredited by the Council on Social Work Education.

• Minimum one year experience working with frail and elderly population. (3+ years social work experience preferred).

• Experience conducting psychosocial assessments, care planning and case management skills required.

• Demonstrated ability to work in a multicultural and multidisciplinary team environment.

• Excellent oral and verbal communication and meeting facilitation skills

• Previous experience assisting persons with behavioral health & substance abuse issues, preferred.

• Bilingual ability preferred (Mandarin, Cantonese and Spanish)

• Current CPR certification or the ability to obtain CPR certification is required.

• Require personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law.

Location

• Los Angeles required.

• On Site at Seen Health in Alhambra; home and community facility visits as needed.

• Relocation benefits available.

Salary & Benefits

• Salary is competitive and includes benefits.