PACE Social Worker: Care Coordinator & Advocate

Pace Ri; Newport (RI); On-site; USD 52,000 - 76,000; Full time

Job summary

The Pace RI Social Worker is a core member of the PACE Interdisciplinary Team, collaborating with PCPs, RNs and caregivers to support health and social goals. You will conduct psychosocial assessments, provide education, case management, and coordinate services in the community and home settings.

Responsibilities include enrollment support, coordinating care plans, liaison with providers, and documentation in the electronic health record, ensuring the participant’s rights and safety throughout

Qualifications

• Master of Social Work Degree is required.
• 2 years of relevant direct service work, required.
• 1–2 years of case management experience, preferred.
• EMR experience (Cognify), preferred.
• 1 year of experience within a health care organization, preferred.
• Substantial experience in substance use treatment, preferred.
• Rhode Island Clinical Social Worker or Independent Clinical Social Worker license (not required to apply/interview).

Responsibilities

• Provide orientation, information, and resources to community members, participants and caregivers about PACE policies and services.
• Social worker assigned a Traditional Adult Day caseload collaborates with day center staff to enroll participants, determine insurance eligibility, and enter information into the SAMS system as required.
• Conduct comprehensive biopsychosocial assessments as per policy and standards.
• Assist in development and delivery of a community-based care plan and related services to maintain/improve health.
• Attend intake meetings and provide input on potential enrollees based on social work assessment.
• Serve as liaison between IDT, service providers and participant/caregivers for timely communication.
• Coordinate respite stays and discharge planning with staff.
• Monitor community long-term care services for adherence to plan of care; participate in care conferences.
• Identify behavioral health needs and oversee behavioral health services; liaise with providers.
• Identify caregiver support needs and provide resources or facilitate groups.
• Provide staff and participant education in group programs as assigned.
• Make protective service reports as required by law.
• Complete insurance and co-pay documentation for traditional adult day participants.
• Assist with entitlements access (housing, Medicaid, SNAP) and PACE rep payee.
• Assist with other aspects of Traditional Adult Day programming as needed.
• Assist with disenrollment from PACE and Traditional Adult Day and plan continuity of care.
• Document all interactions in the EMR.

Skills

Confidentiality

Task prioritization

MS Office

Punctuality

English literacy

Communication under stress

Policy interpretation

Education

Master of Social Work Degree

Tools

Cognify EMR

Job description

The Pace RI Social Worker is a core member of the PACE Interdisciplinary Team, collaborating with PCPs, RNs and caregivers to support health and social goals. You will conduct psychosocial assessments, provide education, case management, and coordinate services in the community and home settings.

Responsibilities include enrollment support, coordinating care plans, liaison with providers, and documentation in the electronic health record, ensuring the participant’s rights and safety throughout