PACE Master's Level Social Worker

Valir Health; Shawnee (OK); On-site; USD 48,000 - 64,000; Full time

Benefits offered by this job

Competitive pay

Retention bonuses

Referral bonuses

Medical insurance

Dental insurance

Vision insurance

Birthday leave

401K match

Life insurance

PTO

Career growth

Recognition program

Job summary

Valir Health in Shawnee, OK is seeking a dedicated professional to coordinate transitions of care, mental and psychosocial support for seniors in the PACE program. The role involves counseling on financial planning and ensuring patient wishes are enacted.

You will advocate for participants, lead care planning discussions, and collaborate with care teams to arrange beds and coordinate services, with a focus on compassionate, person-centered care.

Responsibilities

• Serves as primary point of contact for transitions of care and coordinates bed placements across care settings.
• Organizes access to community resources and supports for participants and families.
• Provides case management services and assists with DNR and Advanced Directives planning.

Job description

Job Details: Job Location: Shawnee, OK 74801, Position Type: Full Time, Job Shift: Day, Valir PACE provides integrated medical and social services to our most vulnerable seniors, helping to unlock their full potential. We are looking for team members who are energized by working in diverse teams toward our shared purpose. Those eager to drive groundbreaking innovation, and who will interact with those we serve and those who serve them in a spirit of understanding and compassion.

WHAT WE OFFER

• Competitive pay, retention and referral bonuses
• Outstanding Medical, dental, and vision insurance
• Paid day off for your birthday
• 401K Company match on day one
• Company paid life insurance
• Generous PTO
• Career development opportunities
• Employee Recognition

#PACE

About the Role: Job Summary: The position serves as a primary source to coordinate all transitions of care, mental, and psychosocial care as well as counsels participant on financial and advanced care planning options including advanced directives, DNR, etc. Advocates for participants and ensures participants’ wishes are enacted.

Duties/Responsibilities:

• Serves as primary point of contact for all transitions of care. Arranges for beds as needed for appropriate level of care (acute, post-acute, hospice, etc), coordinates all necessary team members including PACE IDT, external care providers, pharmacy, transportation, etc.
• Finds and obtains access to community resources to support participants and their families. Also organizes caregiver and other appropriate support groups for participants. Identifies resources to meet the psychosocial needs of each participant.
• Responsible for providing case management services for patients
• Assists participants and families with DNR, Advanced Directives, etc. as needed with an emphasis on ensuring patient’s AD’s are congruent with their disease process. Actively supports participant’s development of end of life plan that is well defined, communicated to family and care team and is in line with participant’s wishes.
• Performs annual and bi-annual assessments and status change assessments as indicated by Federal and State regulations.
• Performs routine mental health assessments including depression, anxiety and care giver burnout and makes appropriate referral for mental health services and caregiver support as needed.
• Provides and recommends participants attendance to appropriate group counseling to support effective mental health hygiene and coping skills for participants.
• Facilitates care planning meetings, family meetings, and meetings with other care teams such as nursing home, etc.
• Assist with providing escort services to participant appointments when needed to advocate for participant
• Any and all other duties and responsibilities as assigned.