PACE Social Services Support Specialist

Neighborhood Healthcare; Riverside (CA); On-site; USD 42,000 - 56,000; Full time

Job summary

Neighborhood Healthcare seeks a Social Services Support Specialist to help deliver non-clinical psychosocial services within the PACE program. You will support documentation, coordinate community resources, and assist families in navigating care options.

Working under Social Work Manager, you’ll promote safety, well-being, and independence, aging in place at home as long as possible. This onsite, Monday–Friday role emphasizes collaboration, confidentiality, and compassionate customer service.

Qualifications

• Bachelor’s degree in Social Work or a related field is required.
• Associate degree plus 2 years of relevant experience may be considered.
• One year of social work experience is preferred.
• Bilingual English/Spanish is preferred.
• BLS/CPR First Aid certification required on hire.

Responsibilities

• Assist Social Workers by organizing documentation and communications to support care planning.
• Coordinate referrals to community resources such as food, housing, and caregiver support services.
• Document progress in EMR and track service referrals.
• Prepare for and attend care team meetings, taking notes as needed.

Skills

Verbal communication

Written communication

Bilingual English/Spanish

Education

Bachelor's degree or higher in Social Work/related field

Associate degree + 2 years related experience

Job description

About Us

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

ROLE OVERVIEW And PURPOSE

Working under the supervision of the Social Work Manager, the Social Services Support Specialist supports the delivery of high-quality, non-clinical psychosocial services to participants enrolled in the PACE program. This role focuses on administrative support, coordination of community resources, and assistance to participants and their families in navigating the PACE system. The Social Services Support Specialist plays an important role in promoting participants’ safety, well‑being, and independence- with the goal of helping them age in place and remain safely at home for as long as possible.

Schedule: Monday-Friday, 8am-5pm. This position is onsite.

• Assist MSW Social Workers by managing documentation, organizing participant communications, and preparing community resource materials, enabling clinical staff to focus on direct support and care planning
• Help coordinate referrals to community resources such as food assistance, housing programs, utility assistance, and caregiver support services
• Follow up on service referrals and document progress in the participant's electronic medical record (EMR)
• Assist in organizing participant care team meetings or interdisciplinary team (IDT) meetings by preparing documents and taking notes as needed
• Support the Social Workers in discharge planning coordination (e.g., gathering paperwork, arranging transport, confirming resources)
• Help maintain accurate and up-to-date resource lists, contact logs, and participant communication records
• Participate in team huddles and departmental meetings, providing input on logistical or service coordination issues
• Provide friendly, culturally competent customer service to participants and caregivers via phone, email, or in person
• Serves as a liaison between the PACE Social Worker and the Participant or the Participant’s decision-maker, providing instruction, guidance, or advice
• Provides telephone support and visits Participants in their homes when indicated
• Ensures confidentiality and compliance with HIPAA and organizational policies
• Participates in Participant group activities, support groups, outings, etc.
• May require local travel to participant homes or community organizations

About Us

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

ROLE OVERVIEW And PURPOSE

Working under the supervision of the Social Work Manager, the Social Services Support Specialist supports the delivery of high-quality, non-clinical psychosocial services to participants enrolled in the PACE program. This role focuses on administrative support, coordination of community resources, and assistance to participants and their families in navigating the PACE system. The Social Services Support Specialist plays an important role in promoting participants’ safety, well‑being, and independence- with the goal of helping them age in place and remain safely at home for as long as possible.

Schedule: Monday-Friday, 8am-5pm. This position is onsite.

Responsibilities

• Assist MSW Social Workers by managing documentation, organizing participant communications, and preparing community resource materials, enabling clinical staff to focus on direct support and care planning
• Help coordinate referrals to community resources such as food assistance, housing programs, utility assistance, and caregiver support services
• Follow up on service referrals and document progress in the participant's electronic medical record (EMR)
• Assist in organizing participant care team meetings or interdisciplinary team (IDT) meetings by preparing documents and taking notes as needed
• Support the Social Workers in discharge planning coordination (e.g., gathering paperwork, arranging transport, confirming resources)
• Help maintain accurate and up-to-date resource lists, contact logs, and participant communication records
• Participate in team huddles and departmental meetings, providing input on logistical or service coordination issues
• Provide friendly, culturally competent customer service to participants and caregivers via phone, email, or in person
• Serves as a liaison between the PACE Social Worker and the Participant or the Participant’s decision-maker, providing instruction, guidance, or advice
• Provides telephone support and visits Participants in their homes when indicated
• Ensures confidentiality and compliance with HIPAA and organizational policies
• Participates in Participant group activities, support groups, outings, etc.
• May require local travel to participant homes or community organizations

Qualifications

Education/Experience

• Bachelor's Degree in Social Work, Psychology, Sociology, Counseling, Human Services, Public Health, Education or a related field required; OR Associate's Degree in Social Work, Psychology, Sociology, Counseling, Human Services, Public Health, Education or a related field AND 2 years of case management support, outreach, or resource coordination may be considered in lieu of a bachelor’s degree
• One year of social work experience preferred
• One year of experience working with the elderly population preferred
• Bilingual (English/Spanish) preferred
• Current Basic Life Support (BLS) certification required upon hire and must be maintained as a condition of employment. These courses must follow AHA guidelines- may be completed through approved online providers such as ProMed or other equivalent programs that meet recognized BLS standards
  • In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually.

Additional Qualifications (Knowledge, Skills And Abilities)

• Excellent verbal and written communication skills, including superior composition, typing, and proofreading skills
• Ability to interpret a variety of instructions in written, oral