Senior Social Worker – Transitions of Care

VALIR PACE LLC; Shawnee (OK); Sur place; USD 55 000 - 75 000; Plein temps

Avantages offerts par ce poste

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

Résumé du poste

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.

Responsabilités

• 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.

Connaissances

Care coordination

Case management

Patient advocacy

Communication

Empathy

Description du poste

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.