MSW Social Worker — On-Site & Field Care Navigator

InnovAge; California (MO); On-site; USD 55,000 - 77,000; Full time

Job summary

InnovAge is seeking an MSW to deliver on-site social work services at our center and in field settings, supporting participants and caregivers across care transitions.

The role includes comprehensive psychosocial assessments, care planning, discharge planning, and strong collaboration with the interdisciplinary team to ensure coordinated, quality care in line with InnovAge policies and regulatory requirements.

Responsibilities

• Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
• Completes in-person reassessments at least every six months or as required.
• Performs in-home visits as required by regulations or as indicated
• Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
• Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
• Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined.
• Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.
• Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
• Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
• Documents housing encounters in EPIC
• Collaborate with comfort care team for end-of-life activities
• Assists participant’s family with end-of-life coordination
• Collaborates with RN Case Management on hospitalizations, and provides psychosocial input
• May serve as back-up to RNCM.
• Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate.
• Coordinates guardianship process for participants lacking decision‑making capacity without a surrogate.
• Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported.
• Provides options counseling when appropriate
• Assists participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork.

Job description

InnovAge is seeking an MSW to deliver on-site social work services at our center and in field settings, supporting participants and caregivers across care transitions.

The role includes comprehensive psychosocial assessments, care planning, discharge planning, and strong collaboration with the interdisciplinary team to ensure coordinated, quality care in line with InnovAge policies and regulatory requirements.