PACE Geriatric Services Specialist - Per Diem (Central Valley PACE - Modesto)

Central Valley PACE; Modesto (CA); On-site; USD 30,000 - 42,000; Full time

Job summary

Central Valley PACE in Modesto, CA seeks a Clinical Employee to support patients through screening, assessment, planning, coordination of services, counseling and referrals. Schedule: Monday - Friday per diem with 6:00am-6:00pm availability. Duties include team assessments, care planning, 24-hour care coordination and discharge planning.

Per diem hours may range from 2–8 hours/day up to 20 hours/week. Qualifications include a Master’s in Social Work, CA Driver’s license, CPR certification, and

Qualifications

• Must have excellent oral and written communication skills.
• Valid CA Driver's License, acceptable driving record, and vehicle insurance
• Proficient in Microsoft applications and use of electronic health data systems
• Demonstrates ability to be culturally sensitive and respect diversity; passion for service; self-starter and highly organized; ability to prioritize, and complete a large volume of work within strict deadlines; provide prompt, efficient and responsive customer service.
• Individual therapy skills for geriatric participants, analytical thinking and problem solving abilities.

Responsibilities

• Participates in the Multidisciplinary Team's initial assessments, care planning and periodic re-assessments (minimally every six months) of participant's case.
• Maintains current written case management records, including periodic reassessments of program participants.
• Coordinates 24 hour care delivery. Provides individual and family counseling, develops and leads group counseling and activities.
• Refers participants and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.
• Encourages effective relationships among staff geared to team building and maintenance of a cohesive team.
• Consults with and advises staff members as to the relationship of social, emotional and cultural factors to health and medical care, and as to the availability of social services in the community.
• Participates in Program and Policy development of Social Work component.
• Documents participant changes appropriately in the medical record.
• Assumes responsibility for implementation and coordination of the discharge plan.
• Participates as a member of the Interdisciplinary Team. Attends staff meetings and takes part in participant care planning.
• Observe each participant for any change in physical, mental, emotional and social functioning and shall report such changes to the licensed nurse.
• Assists in providing information and education regarding PACE services, acting as a liaison between different disciplines, services and participants to ensure continuity of care and services.
• Address any participants’ inquiries, providing guidance and assistance with any coordination and delivery of services.
• Facilitates communication among service providers, family, participants, and caregivers.
• Conducts home visits, hospital visits, nursing skill facilities visits as required.
• Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
• Other projects and duties as assigned.

Skills

Oral and written communication

Cultural sensitivity

Organizational skills

Education

Master's Degree in Social Work

BLS CPR Certification

Two years health-related experience (preferred)

Job description

Job Category: Clinical Employee

Requisition Number: PACEG004761

• Posted : September 4, 2026
• Full-Time

Locations

Showing 1 location

Modesto, CA 95355, USA

Description

Responsible for providing support and advocacy services to patients of the Central Valley PACE program, including participant screening, assessment, planning, coordination of patient services and care, counseling and referral.

Schedule: Monday - Friday - Per Diem (as needed). This position requires availability between the hours of 6:00am-6:00pm. Work hours will vary based on need, with shifts ranging from 2 to 8 hours per day when called upon, not exceeding 20 hours per week.

Compensation:

Duties and Responsibilities

• Participates in the Multidisciplinary Team's initial assessments, care planning and periodic re-assessments (minimally every six (6) months) of participant's case. Assessments are to be completed prior to the scheduled team meeting. Communicates participant changes to team members.
• Maintains current written case management records, including periodic reassessments of program participants.
• Coordinates 24 hour care delivery. Provides individual and family counseling, develops and leads group counseling and activities.
• Refers participants and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.
• Encourages effective relationships among staff geared to team building and maintenance of a cohesive team.
• Consults with and advises staff members as to the relationship of social, emotional and cultural factors to health and medical care, and as to the availability of social services in the community.
• Participates in Program and Policy development of Social Work component.
• Documents participant changes appropriately in the medical record.
• Assumes responsibility for implementation and coordination of the discharge plan.
• Participates as a member of the Interdisciplinary Team. Attends staff meetings and takes part in participant care planning.
• Observe each participant for any change in physical, mental, emotional and social functioning and shall report such changes to the licensed nurse.
• Assists in providing information and education regarding PACE services, acting as a liaison between different disciplines, services and participants to ensure continuity of care and services.
• Address any participants’ inquiries, providing guidance and assistance with any coordination and delivery of services.
• Facilitates communication among service providers, family, participants, and caregivers.
• Conducts home visits, hospital visits, nursing skill facilities visits as required.
• Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
• Other projects and duties as assigned.

Physical Demands

• Ability to lift up to 30 pounds. Moving, lifting or transferring patients may involve lifting or pushing greater than 30 pounds, should be done with assistance as appropriate.
• Must be able to hear staff on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.
• Must have vision with or without lenses that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.
• Must have high manual dexterity.
• Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.
• Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment.
• Moderate pressure to meet scheduled appointments while dealing with frail and confused participants.
• Subject to unpleasant odors.
• The noise level in the work environment is usually quiet to moderate.

Education/Experience Requirements

Minimum Qualifications

• Must have excellent oral and written communication skills.
• Valid CA Driver's License, acceptable driving record, and vehicle insurance
• Proficient in Microsoft applications and use of electronic health data systems, at a minimum level have good computer literacy including internet navigation and research skills.
• Demonstrates ability to be culturally sensitive and respect diversity, work effectively with individuals of different cultures and socio-economic status; passion for service; self-starter and highly organized; ability to prioritize, and complete a large volume of work within strict time deadlines; provide prompt, efficient and responsive customer service.
• Individual therapy skills for geriatric participants, analytical thinking and problem solving abilities.
• Meet a standardized set of competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently.

Education/Experience

• Master's Degree from an accredited school of Social Work.
• Current BLS CPR Card certified by the American Heart Association
• Two (2) years health related experience preferred.
• Minimum one (1) year experience working with the frail or elderly population, preferred.

Equal Opportunity Employer
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