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About the Role

The Social Worker will provide comprehensive social work services to participants, addressing psychological, psychosocial, financial, environmental, and interpersonal matters. Services will be delivered in various settings, including homes, the PACE site, and community locations. The role involves acting as a liaison between participants, their representatives, the Interdisciplinary Care Team, and community agencies to ensure participant satisfaction and support throughout their care journey. This includes providing concrete services, crisis intervention, and end-of-life care support.

Responsibilities

• Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations.
• Assist participants with personal and environmental challenges that may interfere with benefiting from the PACE program.
• Educate participants and their authorized representatives on community, health, and public services and benefits to promote safe community living.
• Assist with referrals, service coordination, and document completion for community resources.
• Ensure timely and appropriate communication and care coordination during and after hospitalizations or inpatient stays.
• Report all communication with facilities and hospitals to the IDT and document accordingly.
• Provide social work consultation, education on treatment options (including palliative and end-of-life care), and coordinate services.
• Arrange bereavement assistance, supportive counseling, or other behavioral health services as needed.
• Provide caregiver support.
• Complete biopsychosocial assessments, cognitive/emotional status assessments, and other required assessments.
• Complete HCP documents and facilitate the completion of advance directives (DNR/DNI/DNH/MOLST).
• Assure participant-focused Care Plan psychosocial goals and interventions are applied.
• Utilize EMR for assessment completion and other necessary systems.
• Ensure documentation is completed timely (within 48 hours) and accurately.
• Organize and manage workload to provide appropriate and maximized social services.
• Use case management and clinical skills to help participants and families resolve health-related social, financial, and psychological problems.
• Ensure timely and appropriate coordination and follow-through of care and services.
• Integrate best practices into participant care by collaborating with internal and external professionals.
• Facilitate psycho-educational presentations for participants in day health centers.
• Attend and actively participate in IDT and care plan meetings.
• Identify, document, and present social work-related concerns, issues, interventions, and recommendations in IDT meetings.
• Ensure social work interventions are applied and participant-centered goals are met.
• Participate in continuing education and professional training programs.
• Participate in staff enhancement through approved seminars/workshops.
• Participate in peer supervision conferences and individual conferences with the Social Work Manager.
• Represent the Social Work department and CenterLight Healthcare at community meetings and conferences.
• Act within the scope of individual authority to practice.
• Meet standardized competencies before working independently.
• Act as a member of the IDT.
• Perform other duties as assigned by supervisor.

Requirements

• One (1) year experience in a health care setting.
• Minimum of one (1) year of experience working with a frail or elderly population.
• If less than one year of experience, must receive appropriate training upon hiring.
• Experience in home care and/or field work is preferred.
• Regular access to a car for field visits is preferred but not required.
• Must have active NY State Social Work license.
• Be legally authorized to practice in the State of New York.
• Be medically cleared for communicable diseases and have all immunizations up-to-date.
• Individuals must be able to sustain physical requirements essential to the job, including standing, sitting, lifting up to 50 pounds, bending, squatting, maneuvering stairs, walking, agility, fine motor skills, visual assessment, hearing, speaking clearly, and demonstrating good decision-making and cognitive ability.

Skills

• Advocating
• Assessing
• Assisting
• Collaborating
• Educating
• Evaluating
• Implementing
• Planning
• Psychological assessment
• Psychosocial assessment
• Financial assessment
• Environmental assessment
• Interpersonal assessment
• Case management
• Clinical skills
• Communication
• Coordination of care
• Discharge planning
• Crisis intervention
• End of life care
• Caregiver support
• Biopsychosocial assessment
• Cognitive/emotional status assessment
• Advance care planning
• EMR utilization
• Documentation
• Psycho-educational presentation
• Interdisciplinary collaboration

Location

• Various settings including participant's home, PACE site, community settings (hospital, SNF, ALF, etc.)

Work Type

• Full-time
• Onsite
• Field visits

Experience Level

• 1 year experience in a health care setting
• 1 year experience working with a frail or elderly population

Education Level

• M.S.W. from an accredited college or university

Salary/Compensations

• $85,280.00 - $102,960.00

About the Company

• CenterLight Healthcare

Equal Opportunity

• We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information.
• We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.