Geriatric Medical Social Worker – Care Team Partner

Institute on Aging; San Francisco (CA); On-site; USD 86,000 - 102,000; Full time

Job summary

Institute on Aging (On Lok PACE) in San Francisco seeks a Medical Social Worker to provide psychosocial assessment and therapeutic counseling to a caseload of older adults with complex medical and psychosocial needs. This role serves as the liaison between participants, families, and the interdisciplinary care team.

The position emphasizes collaboration with primary care providers, nurses, and IDT members to coordinate care, promote goal-directed plans, and facilitate transitions, end-of-life

Qualifications

• MSW from an accredited school of Social Work.
• At least one year of professional experience with frail elderly.
• At least one year of experience in an interdisciplinary care model.
• Licensure is not required but supervision toward LCSW licensure is provided.

Responsibilities

• Conducts in-depth biopsychosocial assessments to determine participant needs.
• Utilizes evidence-informed interventions to develop participant-centered care plans.
• Collaborates with Primary Care Providers and RNs to form the core primary care team.
• Maintains a care management relationship with participants and their support networks.
• Coordinates care for participants with complex needs across services.
• Provides supportive counseling and crisis intervention.
• Facilitates family and care team meetings for end-of-life planning and goals of care.
• Cultivates partnerships with community providers to extend interventions.
• Educates participants on available resources and self-management.

Skills

Psychosocial assessment

Interdisciplinary team collaboration

Crisis intervention

Strong communication

Bilingual (Cantonese/Spanish)

Education

MSW from accredited school

Tools

Electronic Health Records (EHR)

Job description

Institute on Aging (On Lok PACE) in San Francisco seeks a Medical Social Worker to provide psychosocial assessment and therapeutic counseling to a caseload of older adults with complex medical and psychosocial needs. This role serves as the liaison between participants, families, and the interdisciplinary care team.

The position emphasizes collaboration with primary care providers, nurses, and IDT members to coordinate care, promote goal-directed plans, and facilitate transitions, end-of-life