Overview
The social work coordinator develops and maintains a therapeutic relationship with the participant to optimize participant functioning by providing quality services in conjunction with the interdisciplinary team. The social worker will conduct initial, sixth month and as necessary, face to face biopsychosocial assessments with each of the participant’s strengths and limitations. The social worker develops an individualized life plan with the participant identifying his or her goals and implementing interventions to assist with achieving their goals. The social worker always works within an interdisciplinary team, collaborates with team members and advocates for the participant when necessary. The social worker is expected to make home visits when necessary and communicates with supervisors and other team members when there is a change in mood and or behavior. The social worker assists with concrete services and helps the participant adjust to difficult life challenges such as medical conditions.
Responsibilities
Essential Functions
- Assesses participants/family psychosocial status and social work needs utilizing professional knowledge, skills of observations and interviewing skills.
- Assesses a member’s living condition/situation, cultural influences, and support systems to identify member’s strengths and deficits.
- Hospital and Skilled Nursing Facility liaison/Discharge Planner
- Assesses a member’s need for Money Management Services, as needed.
- Develops and implements the social work components and works with other team members to develop a comprehensive Interdisciplinary team plan of care based on the needs of participant and caregivers, and goals mutually acceptable to the member/family and significant others
- Monitors effectiveness and outcomes regularly and keeps the team informed as to participant progress and level of need. Remains alert to pertinent input from other team members, participants and family members/caregivers. Reviews and revises goals and approaches to member/ family care in coordination with interdisciplinary team members.
- Provides initial face-to-face psychosocial assessments of new members enrolled in the program, and face-to-face reassessments at appropriate intervals according to PACE standards and the individualized needs of each participant
- Provides ongoing in-person and telephonic assessments and services to identified participants, family, including emotional support, reassurance, assistance with community resource planning and crisis intervention.
- Coordinates with the Entitlement Coordinator to ensure that entitlements and benefits are in place and re-certified annually.
- Provides advocacy to member/family, e.g., assistance in obtaining entitlements and community services and resources
- Coordinates with the Interdisciplinary Team (IDT) on obtaining of Advance Directives. Provides education to participants, designated representatives and family members on their right to develop Advance Directives which may include Health Care Proxy, Living Will, DNR, MOLST, Durable Power of Attorney and or Burial Plans.
- Educates and assesses participants/family understanding and ability to pay surplus and entitlements. Coordinates with participants/caregivers, discharge planners, physicians and social workers during hospitalizations, subacute rehabilitation stays and Long Term Care Placement for continuity of care
Salary Range: $73,863-$79,214/yearly
Qualifications
LMSW
Bi-Lingual Plus
Case Management Experience
Geriatric Experience