PACE Master's Level Social Worker

VALIR PACE LLC; Shawnee (OK); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Competitive pay

Bonuses for retention and referrals

Medical, dental, and vision insurance

Birthday day off

401K company match on day one

Company paid life insurance

Generous PTO

Career development opportunities

Employee recognition

Job summary

VALIR PACE LLC is seeking a dedicated care coordination specialist to oversee transitions of care, manage psychosocial assessments, and counsel participants on financial and advance care planning options including directives and DNR.

You will advocate for participants, coordinate a multidisciplinary team, arrange beds as needed, access community resources, and support families through end-of-life planning. Strong communication and empathy are essential.

Qualifications

• Coordinate transitions of care for participants across settings.
• Advocate for participants and ensure wishes align with care plans.
• Identify community resources and arrange caregiver support.

Responsibilities

• Serve as primary contact for transitions of care, coordinating team members and providers.
• Facilitate care planning and family meetings, including end-of-life planning.
• Assist with DNR and Advanced Directives and ensure documentation matches disease process.
• Provide escorts to appointments and advocate for participant needs.
• Conduct mental health screenings and refer for services as needed.

Skills

Care coordination

Case management

Patient advocacy

Communication

Empathy

Job description

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 OFFERCompetitive pay, retention and referral bonusesOutstanding Medical, dental, and vision insurancePaid day off for your birthday401K Company match on day oneCompany paid life insuranceGenerous PTOCareer development opportunitiesEmployee Recognition#PACEJob 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 patientsAssists 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 participantAny and all other duties and responsibilities as assigned.