Social Worker
Core
Provide comprehensive social work services, psychosocial assessments, and case management for elderly participants in the PACE program, with a focus on a Chinese-speaking population.
Role type
Clinical Social Worker (Case Management)
Builds
Individualized care plans and integrated support services for seniors
Domain
Healthcare / Elderly Care / PACE Program
Required skills
Psychosocial assessment, Case management, Care planning, Behavioral health support, Discharge planning, Interdisciplinary coordination, Clinical documentation, Regulatory compliance
Preferred skills
Experience with frail elderly, Substance abuse counseling
Technologies
Electronic health record systems
Responsibilities
Conduct psychosocial assessments to evaluate participant needs, Develop and implement individualized care plans, Coordinate care with physicians, nurses, therapists, and community providers, Communicate with participants and families regarding care needs and transitions, Arrange social services and facilitate care transitions, Maintain accurate clinical documentation, Participate in interdisciplinary team meetings and quality improvement activities
Seniority
Mid-level, hands-on IC