Geriatric Social Worker – Care Coordination & Support

Talent-Connect-Now; Los Angeles (CA); On-site; USD 60,000 - 90,000; Full time

Job summary

Talent Connect Executive Search & HR Solutions is recruiting a Social Worker for a healthcare organization operating Programs of All-Inclusive Care for the Elderly (PACE). The role focuses on psychosocial support, care coordination, and advocacy for older adults with complex needs.

As part of an interdisciplinary team, you will help participants and families address emotional, social, and practical challenges that affect well-being and community living.

Qualifications

• MSW from an accredited university.
• Strong psychosocial assessment, care planning, and resource coordination skills.
• Ability to support older adults and families navigating complex healthcare and social service needs.
• Strong communication, documentation, and problem-solving skills.
• Ability to collaborate effectively with a multidisciplinary healthcare team.
• Commitment to respectful, culturally responsive, participant-centered care.

Responsibilities

• Complete psychosocial assessments and evaluate support systems, caregiver needs, safety concerns, and barriers to care.
• Develop and implement individualized social work interventions aligned with care plans.
• Provide counseling and education to participants and caregivers on adjustment to illness and caregiver stress.
• Connect participants with community resources, benefits assistance, caregiver support, and behavioral health services.
• Participate in IDT meetings and communicate psychosocial concerns to monitor progress.
• Collaborate with clinical staff to support care transitions after hospitalization or changes at home.
• Facilitate advance care planning discussions and refer to appropriate resources.
• Assist with discharge or disenrollment coordination to ensure continuity of care.
• Recognize and report concerns involving abuse, neglect, or safety as required.
• Maintain accurate documentation of assessments, interventions, referrals, and outcomes.
• Coordinate referrals when specialized clinical support is needed.

Skills

Psychosocial assessment

Care planning

Resource coordination

Communication skills

Documentation skills

Interdisciplinary collaboration

Cultural sensitivity

Bilingual English/Spanish

Education

MSW from an accredited university

Tools

Electronic Health Records (EHR)

Job description

Talent Connect Executive Search & HR Solutions is recruiting a Social Worker for a healthcare organization operating Programs of All-Inclusive Care for the Elderly (PACE). The role focuses on psychosocial support, care coordination, and advocacy for older adults with complex needs.

As part of an interdisciplinary team, you will help participants and families address emotional, social, and practical challenges that affect well-being and community living.