PACE Social Worker: Elder Care Case Manager & Advocate

Appalachian Agency For Senior Citizens Inc; Bristol (VA); On-site; USD 63,000 - 74,000; Full time

Job summary

Appalachian Agency For Senior Citizens Inc. is seeking a PACE Social Worker to deliver direct social work case management for participants, including intake, screening, counseling and referrals.

You will evaluate new enrollees and coordinate intake and marketing activities, ensuring seamless care coordination. The role requires a Master’s in Social Work, at least one year serving frail/elderly populations, HIPAA compliance, and current immunizations.

Qualifications

• Master’s Degree in social work from an accredited school of social work.
• A minimum of one year’s experience working with a frail or elderly population.
• Compliance with any State or Federal requirements for direct patient care staff in their respective settings.
• Valid driver’s license.
• Pass a criminal background check.
• Medically cleared of communicable diseases and up-to-date with immunizations.

Responsibilities

• Evaluates potential program enrollees to determine participant needs and eligibility for enrollment.
• Completes intake and enrollment documentation.
• Participates in the Interdisciplinary Teams’ initial assessments, care planning and on-going evaluations of participants.
• Conducts periodic assessments in the home.
• Facilitates the development of the IDT Plan of Care.
• Refers participants to appropriate community agencies or facilitates, acts as a liaison with such organizations and as advocate for participants.
• Coordinates all level of care decisions with State Health and Human Services Personnel.
• Participates in interdisciplinary team, management team, and other related meetings and activities.
• Participates in marketing activities.
• Participates in program and policy development of the social work component of the program.
• Complies with HIPAA requirements and maintains strict confidentiality in all matters pertaining to PACE participants and program operations.
• Completes appropriate documentation related to participant assessments as required.
• Ensures timely, complete communication of referral services into the electronic medical record.
• Assists with staff development and training.
• Participates in the Quality Improvement program.
• Oversees disenrollment process including facilitating a participant’s reinstatement in other Medicare and Medicaid programs and developing a transition plan to community services.
• Complies with Mandated Reporter requirements reporting any suspected abuse, neglect or exploitation to the appropriate authorities.
• Maintains required statistical data.

Education

Master’s Degree in social work

Job description

Appalachian Agency For Senior Citizens Inc. is seeking a PACE Social Worker to deliver direct social work case management for participants, including intake, screening, counseling and referrals.

You will evaluate new enrollees and coordinate intake and marketing activities, ensuring seamless care coordination. The role requires a Master’s in Social Work, at least one year serving frail/elderly populations, HIPAA compliance, and current immunizations.