Social Work Case Manager

Innovative Integrated Health, Inc.; Fresno (CA); On-site; USD 58,000 - 78,000; Full time

Benefits offered by this job

401(k)

Dental insurance

Employee assistance program

Employee discount

Flexible spending account

Health insurance

Health savings account

Life insurance

Paid sick time

Paid time off

Referral program

Retirement plan

Vision insurance

Job summary

PACE by IIH is seeking a Social Work Case Manager to provide direct social work case management services to participants.

You will collaborate with an interdisciplinary team, coordinate family meetings, maintain records, and advocate for participants' needs while ensuring compliance and confidentiality.

The role requires engagement with community resources, discharge planning, and support across agency partnerships to promote independence and quality of life for seniors at home.

Qualifications

• Interest in risk-based long-term care for frail elderly in the community.
• Experience with social service principles and practices.
• Knowledge of psychosocial needs of the elderly.
• Familiarity with Medicare/Medicaid financing and PPS.
• Understanding of aging network and local service systems.
• Ability to work in an interdisciplinary team.
• Strong written and verbal communication and documentation.
• Computer literacy and ability to maintain records.

Responsibilities

• Follow directives from IDT and meet with families as needed.
• Coordinate family meetings and ongoing case management.
• Advocate for participants and coordinate discharge planning.
• Maintain thorough case management records and preferences.
• Liaise with agencies such as Aging, SSA, Medicaid.
• Participate in community meetings and government program applications.
• Identify housing resources and assist with eligibility forms.
• Conduct home visits and assist hard-to-reach participants.
• Maintain confidentiality and participate in staff meetings.

Skills

Interdisciplinary teamwork

IDT collaboration

Social service principles

Elder care knowledge

Medicare/Medicaid knowledge

Aging network awareness

Communication skills

Computer skills

Flexibility

Education

Bachelor’s degree in social work

CPR with First Aid

Immunizations up-to-date

Job description

Who We Are

PACE by IIH is empowering senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving quality of life, promoting independence, and providing compassionate support tailored to the unique needs of each participant. Our team works collaboratively to deliver innovative, community-based healthcare solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to thrive.

• 401(k)
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Who We Are

PACE by IIH is empowering senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support. Through an interdisciplinary and participant-centered model of care, PACE by IIH is committed to improving quality of life, promoting independence, and providing compassionate support tailored to the unique needs of each participant. Our team works collaboratively to deliver innovative, community-based healthcare solutions that allow seniors to remain safely and comfortably in their homes while receiving the care and services they need to thrive.

Benefits

• 401(k)
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

Job Summary

The Social Work Case Manager is responsible for providing direct social work case management services to participants.

Essential Job Functions

• Follow social work directives from interdisciplinary team (IDT) and meet with family members and other community members/agencies as needed.
• Coordinate ongoing family meetings, as needed.
• Provide ongoing case management and advocacy as required.
• In conjunction with the interdisciplinary team, coordinate discharge planning for participants returning home from hospital or nursing facility.
• Maintain current, written case management records, including ongoing documentation of services provided, and participants expressed wishes.
• Act as liaison between the participant and other agencies such as Department of Aging, Social Security Administration, Medicaid, etc.
• Participate in participant-related meetings with external agencies and conferences in the community as needed.
• Assist with ongoing government program financial eligibility applications for participants, including recertification as needed.
• Identify housing resources for participants offered by the community/county. Assist participants with housing resources such as eligibility forms, applications, and navigating various housing options.
• Conduct home visits, as needed.
• Assist in connecting with hard-to-reach participants.
• Maintain confidentiality of participant information.
• Attend and participate in staff meetings, in-services, projects, and committees as assigned.
• Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
• Be flexible in schedule of hours worked.
• May require use of personal vehicle.

Qualifications

Knowledge, Skills, and Abilities

• Interest in the risk-based long-term care program to serve frail elderly in a community-based setting.
• Experience and thorough knowledge of social service principles and practices.
• Knowledge of psychosocial, behavioral, and family needs of the elderly population.
• Knowledge of financing mechanisms such as Medicare, Medicaid, and Prospective Payment Systems.
• Knowledge of the local and social service delivery systems and aging network.
• Proven ability to work in an interdisciplinary team.
• Ability to work effectively and harmoniously with the staff, the elderly, and providers of services, public, and private agencies.
• Energetic, dependable, resourceful, and flexible.
• Effective oral and written communication skills.
• Computer skills required.

Working Conditions and Physical Demands

• Ability to access all areas of the center throughout the workday.
• Ability to lift up to 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another qualified employee when attempting to lift or transfer objects over 25 pounds.
• Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling.
• Ability to communicate verbally with an excellent comprehension of the English language.
• Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-conditioned environment.

Experience

• Preferred one (1) year of documented experience in working with a frail or elderly population required.
• Prefer experience in a community-based setting or geriatric program.

Education and Certification

• Bachelor’s degree in social work or related field required.
• CPR with First Aid certification.
• Is medically cleared for communicable diseases and has all immunizations up-to-date before engaging in direct participant contact.

Core Values

• CARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants.
• COMPASSION in every interaction, ensuring kindness, empathy, and understanding guide our care.
• CULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow.
• COMMUNITY that fosters connection, belonging, and support for participants and their families.
• COMMITMENT to quality improvement, innovation, and delivering healthier outcomes.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.