Geriatric Care Navigator – PACE

Central Valley PACE; Modesto (CA); On-site; USD 30,000 - 42,000; Full time

Job summary

Central Valley PACE in Modesto, CA seeks a Clinical Employee to support patients through screening, assessment, planning, coordination of services, counseling and referrals. Schedule: Monday - Friday per diem with 6:00am-6:00pm availability. Duties include team assessments, care planning, 24-hour care coordination and discharge planning.

Per diem hours may range from 2–8 hours/day up to 20 hours/week. Qualifications include a Master’s in Social Work, CA Driver’s license, CPR certification, and

Qualifications

• Must have excellent oral and written communication skills.
• Valid CA Driver's License, acceptable driving record, and vehicle insurance
• Proficient in Microsoft applications and use of electronic health data systems
• Demonstrates ability to be culturally sensitive and respect diversity; passion for service; self-starter and highly organized; ability to prioritize, and complete a large volume of work within strict deadlines; provide prompt, efficient and responsive customer service.
• Individual therapy skills for geriatric participants, analytical thinking and problem solving abilities.

Responsibilities

• Participates in the Multidisciplinary Team's initial assessments, care planning and periodic re-assessments (minimally every six months) of participant's case.
• Maintains current written case management records, including periodic reassessments of program participants.
• Coordinates 24 hour care delivery. Provides individual and family counseling, develops and leads group counseling and activities.
• Refers participants and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.
• Encourages effective relationships among staff geared to team building and maintenance of a cohesive team.
• Consults with and advises staff members as to the relationship of social, emotional and cultural factors to health and medical care, and as to the availability of social services in the community.
• Participates in Program and Policy development of Social Work component.
• Documents participant changes appropriately in the medical record.
• Assumes responsibility for implementation and coordination of the discharge plan.
• Participates as a member of the Interdisciplinary Team. Attends staff meetings and takes part in participant care planning.
• Observe each participant for any change in physical, mental, emotional and social functioning and shall report such changes to the licensed nurse.
• Assists in providing information and education regarding PACE services, acting as a liaison between different disciplines, services and participants to ensure continuity of care and services.
• Address any participants’ inquiries, providing guidance and assistance with any coordination and delivery of services.
• Facilitates communication among service providers, family, participants, and caregivers.
• Conducts home visits, hospital visits, nursing skill facilities visits as required.
• Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
• Other projects and duties as assigned.

Skills

Oral and written communication

Cultural sensitivity

Organizational skills

Education

Master's Degree in Social Work

BLS CPR Certification

Two years health-related experience (preferred)

Job description

Central Valley PACE in Modesto, CA seeks a Clinical Employee to support patients through screening, assessment, planning, coordination of services, counseling and referrals. Schedule: Monday - Friday per diem with 6:00am-6:00pm availability. Duties include team assessments, care planning, 24-hour care coordination and discharge planning.

Per diem hours may range from 2–8 hours/day up to 20 hours/week. Qualifications include a Master’s in Social Work, CA Driver’s license, CPR certification, and