Impress employers and recruiters.
Choose from hundreds of resume examples.

Impress employers and recruiters.
Choose from hundreds of resume examples.

Target Resume Now

About the Role

Lead and manage Social Work (SW), Homecare services, and Community Nursing across all PACE sites. Ensure high-quality participant-centered social services, contractor oversight, discharge coordination, RCFE admissions and tracking, Level-of-Care (LOC) submission oversight, quality improvement, regulatory compliance, and participant satisfaction/retention.

Responsibilities

• Provide direct supervision, training, coaching, and performance evaluation for social work, homecare, and community nursing teams.
• Ensure effective hiring, orientation, ongoing training, scheduling, coverage, and staffing across all PACE sites for social work, homecare, and community nursing services.
• Delegate responsibilities appropriately according to licensure, credentials, education, and experience.
• Develop policies and procedures for social work, homecare, and home health services.
• Drive participant engagement and retention initiatives, including outreach, care-plan engagement, satisfaction follow-up, and targeted interventions to reduce disenrollment.
• Lead the management and oversight of contracted homecare services, including contractor selection, contract performance monitoring, service-level expectations, invoicing reconciliation, and vendor relationship management.
• Lead the social work team in hospitalization discharge planning and coordination with hospitals, SNFs, IDT, and families to ensure safe transitions and timely return to community-based care.
• Lead RCFE contracting, referral/admission processes, capacity tracking, and ongoing relationship management with RCFE partners.
• Oversee Community RNs in preparing and submitting Level-of-Care (LOC) documentation for PACE candidate applications, including coordinating assessments, required documentation, submission timelines, and follow-up.
• Lead the Social Work team to monitor and resolve participant eligibility issues.
• Oversee the quality of care delivered by homecare caregivers in participants' homes.
• Lead QI initiatives focused on social work and homecare services, tracking QI metrics, and implementing corrective actions.
• Monitor encounter, assessment, and care plan metrics for social work, homecare, and community nursing/home health services and identify opportunities to improve overall participant experience.
• Implement strategies to meet or exceed national and state participant satisfaction benchmarks for social work, homecare services, and behavioral wellness.
• Coordinate closely with PCPs, IDT members, and community providers to develop and implement individualized care and therapy plans.
• Oversee supplies, equipment, and workspace needs relevant to social work, homecare, and community nursing operations across sites.
• Resolve grievances related to social work, homecare, and community nursing issues in collaboration with Center Manager.
• Prepare for and participate in CMS, DHCS, and other regulatory audits and implement corrective actions as needed.
• Ensure accurate, cohesive, and timely documentation in participant medical records for all social work, homecare, and community nursing/home health activities.
• Oversee the quality of care and safety of PACE participants, both at the PACE center and in the community.
• Ensure compliance with all PACE regulatory requirements and internal policies.
• Travel between PACE sites, RCFEs, and participant residences as needed for supervision, training, audits, or to address service issues.
• Utilize Epic appropriately and efficiently and serve as content and workflow expert for resolving issues and proposing solutions in Epic.
• Perform other duties as assigned by the PACE Program Director.

Requirements

• Bachelor’s degree or higher in Social Work, Nursing, Gerontology, Public Health, Health Administration, or a related field.
• Minimum two years of experience in social work, care management, or community-based services.
• Minimum two years supervisory or team-lead experience in a healthcare setting.
• Prior management of multidisciplinary teams strongly preferred.
• Demonstrated skills in supervision, leadership, and communication and in fostering an effective team environment.
• Minimum one year of experience working with older adults and their families in a healthcare or community agency setting is preferred.
• Ability to travel between PACE sites as needed.
• Current BLS and First Aid required.
• Must be able to fluently speak, read and write English.

Skills

• Social Work
• Homecare services
• Community Nursing
• Supervision
• Training
• Coaching
• Performance evaluation
• Hiring
• Orientation
• Scheduling
• Staffing
• Delegation
• Policy development
• Procedure development
• Participant engagement
• Participant retention
• Outreach
• Care-plan engagement
• Satisfaction follow-up
• Discharge planning
• Contract management
• Contractor selection
• Contract performance monitoring
• Invoicing reconciliation
• Vendor relationship management
• RCFE contracting
• Referral processes
• Admission processes
• Capacity tracking
• Level-of-Care (LOC) documentation
• Quality improvement (QI)
• QI metrics tracking
• Corrective action implementation
• Encounter monitoring
• Assessment monitoring
• Care plan monitoring
• Participant satisfaction benchmarking
• Behavioral wellness
• Care plan development
• Therapy plan development
• Supply management
• Equipment management
• Workspace management
• Grievance resolution
• Regulatory audit participation
• Medical record documentation
• Participant safety
• Regulatory compliance
• Travel
• Epic utilization
• Content expertise
• Workflow expertise
• Problem resolution
• Fluency in other languages is an asset

Location

• San Francisco, CA 94133

Work Type

• Full Time

Experience Level

• Minimum two years of experience in social work, care management, or community-based services.
• Minimum two years supervisory or team-lead experience in a healthcare setting.
• Minimum one year of experience working with older adults and their families in a healthcare or community agency setting is preferred.

Education Level

• Bachelor’s degree or higher in Social Work, Nursing, Gerontology, Public Health, Health Administration, or a related field.

Salary/Compensations

• $53.97 - $61.90 Hourly