MSW PACE Social Worker — Home Visits & Care Coordination

Capital Health System, Inc.; Life (TN); On-site; USD 65,000 - 84,000; Full time

Benefits offered by this job

Medical Plan

Dental Plan

Vision Plan

Retirement Savings Plan

Paid Time-Off

Job summary

Capital Health is seeking a social work professional to perform home visits for LIFE program participants. You will coordinate comprehensive plans of care with an interdisciplinary team, perform assessments, and provide counseling to patients and families.

Responsibilities include discharge planning, liaison work with external agencies, and ongoing documentation. A master’s in social work and valid credentialing are required or preferred, with emphasis on elder care experience.

Qualifications

• Master's degree in social work.
• Two years of social work experience.
• One year of experience with frail or elderly population.
• First aid required.
• State license in social work preferred (PACE).
• AHA BLS Driver's License.

Responsibilities

• Promotes collaboration across divisions and fosters team environment.
• Maintains department budget and orders equipment/supplies as needed.
• Understands disaster recovery and business continuity plans.
• Works with participants via home visits and coordinates care planning.
• Coordinates with the IDT to develop comprehensive plans of care.
• Performs intake, reassessments, and ongoing documentation of services.
• Provides counseling and education to participants and families.
• Acts as liaison with external agencies (Aging, SSA, Medicaid).
• Coordinates transitions and discharge planning from hospital or rehab settings.

Skills

Social work experience

Home visits

First aid

BLS certified

Elder care experience

Education

Master's degree in social work

Licensed Social Worker preferred

Job description

Capital Health is seeking a social work professional to perform home visits for LIFE program participants. You will coordinate comprehensive plans of care with an interdisciplinary team, perform assessments, and provide counseling to patients and families.

Responsibilities include discharge planning, liaison work with external agencies, and ongoing documentation. A master’s in social work and valid credentialing are required or preferred, with emphasis on elder care experience.