Geriatric Social Worker (MSW) — Care Coordination & Advocacy

The PACE Place; Jacksonville (FL); Sur place; USD 56 000 - 60 000; Plein temps

Avantages offerts par ce poste

23 days PTO

Full benefits package

Résumé du poste

The PACE Place is seeking a Social Worker to plan, organize, and deliver psychosocial services to participants and families in the PACE program the Jacksonville area.

Responsibilities include assessments, care planning with the IDT, counseling, liaising with agencies, and supporting transitions of care to help participants remain home safely with full benefits. MSW required; 1+ year of elderly care experience preferred.

Qualifications

• Masters of Social Work (MSW) required; must have MSW for interview.
• Minimum one year of experience with frail or elderly population (or training upon hire).
• Two years on an interdisciplinary healthcare or community-based team preferred.
• Must meet PACE competencies prior to working independently.

Responsabilités

• Conduct in-person psychosocial assessments for participants to identify cognitive, emotional, and support needs.
• Collaborate with the interdisciplinary team to develop and update participant care plans.
• Attend daily interdisciplinary team meetings and coordinate 24-hour care delivery.
• Provide education, counseling, and support to participants and caregivers on aging, dementia, grief, family dynamics, and disease processes.
• Facilitate access to housing, financial support, advance care planning, and legal documents (MDPOA, DNR).
• Perform home, hospital, and facility visits for assessment, support, and discharge planning.
• Coordinate care transitions including respite, long-term placement, or disenrollment.
• Maintain timely and accurate documentation in medical records.
• Advocate for participants with external agencies (Adult Protective Services, Housing Authorities).
• Assist with grievances, appeals, and Medicaid eligibility processes.
• Ensure compliance with regulatory and internal documentation and service delivery requirements.
• Participate in continuing education and contribute to quality improvement.

Connaissances

Psychosocial assessment

Case management

Interdisciplinary teamwork

Counseling

Communication

Documentation

Formation

MSW - Master of Social Work

Outils

Microsoft Office

EHR systems

Description du poste

The PACE Place is seeking a Social Worker to plan, organize, and deliver psychosocial services to participants and families in the PACE program the Jacksonville area.

Responsibilities include assessments, care planning with the IDT, counseling, liaising with agencies, and supporting transitions of care to help participants remain home safely with full benefits. MSW required; 1+ year of elderly care experience preferred.