Social Worker

Element Care PACE; Boston (MA); On-site; USD 69,000 - 97,000; Full time

Job summary

Element Care PACE in Boston, MA seeks a Social Worker to participate in planning, implementing and evaluating care plans for older adults in their homes and communities. You will perform initial, semi-annual and annual assessments, contribute to IDT care planning, provide psychosocial counseling, and assist with hospital and skilled nursing admissions and discharges.

You’ll maintain accurate documentation, liaise with families, guardians, Medicaid specialists and community resources, and travel

Qualifications

• Massachusetts social work licensure at the Masters level (L.I.C.S.W. or L.C.S.W.) is required.
• Minimum of 1 year of social work experience with geriatric population.
• Current CPR certification or ability to become certified.
• Ability to treat all participants in a welcoming and professional manner.
• Strong verbal, written and listening skills with ability to multi-task in a fast paced environment.

Responsibilities

• Participates in IDT initial assessments, care planning and ongoing re-assessments.
• Attends IDT meetings and helps develop participant plans of care.
• Completes all assigned assessments (initial, semi-annual, annual, service requests).
• Assesses psychosocial needs and provides counseling with behavioral health providers.
• Facilitates hospital, rehabilitation and NH admissions/discharges; ensures PASRR documentation.
• Assists in conversion from community to long-term care; coordinates with Medicaid and caregivers.
• Arranges and facilitates family meetings; refers to community services.
• Maintains social service documentation in medical records; conducts participant council meetings.
• Educates on health care proxy; assists with HCP completion; liaises with fiscal department.
• Reviews plan of care; completes authorizations for home care; performs visits as indicated.
• Works with Palliative care team on end-of-life planning; provides timely staff communication.
• Reports allegations of abuse and provides resources; required to pass fit tests with respirator seal; frequent local travel.

Skills

Verbal communication

Written communication

Listening

Multi-tasking

Education

MSW license (LISW/LCSW) in MA

CPR Certification

Job description

The Element Care Social Worker participates in the planning, implementation and evaluation of care plans that meet the objectives, standards and policies of the PACE model of care. The social worker demonstrates proficiency in providing traditional social work services in a professional and respectful manner with the goal of helping older adults live safely and comfortably in their homes and communities for as long as they can.

• Participates on the IDT’s initial assessments, care planning and on-going re-assessments of participant care.
• Attends IDT meetings; actively participates in team meetings by sharing pertinent information, providing follow up to assigned tasks and helps to develop participant’s plan of care.
• Completes all assigned assessments – (initial, semi-annual, annual, service request and/or significant event).
• Assesses the psychosocial needs of the participant and provides supportive counseling, working collaboratively with behavioral health providers.
• Facilitates hospital, rehabilitation and nursing home (NH) admissions and discharges as determined by the Interdisciplinary Team. Ensures that PASRR documentation is completed for NH admission.
• Assists in the conversion process of the participant from community to long-term care. Works collaboratively with Medicaid Specialist, skilled nursing facility, and participant’s caregiver to complete conversion. Social
• Arranges and facilitates family meetings, as needed.
• Refers participants and families to appropriate community services and acts as liaison and/or advocate with community organizations for participants.
• Maintains professional, accurate and timely social service documentation in the participants’ medical records.
• Conducts participant council meetings as assigned.
• Works collaboratively with Director of Social Work and Behavioral Health provider to ensure guardianship is up to date. Educates participant regarding health care proxy (HCP). Assists participant in completion of HCP form.
• Works collaboratively with fiscal department to maintain participant insurance benefits and completes required documentation of fiscal information in the medical record.
• Reviews plan of care with participants, guardian, and/or activated health care proxy as assigned.
• Complete authorizations for home care and other approved services timely and accurately.
• Completes home and/or skilled nursing facility visits to assess participant as indicated.
• Works collaboratively with Palliative care team; Assists with end of life planning as indicated.
• Provides timely communication to appropriate staff regarding the following: (disenrollment, conversion to long term care, transfer of sites, participant and/or caregiver demographic changes).
• Reports allegations of abuse to appropriate state agency; provides support and resources to participant as he/she will accept; completes required documentation.
• Ability to pass a fit test. Position requires mask where seal is critical. Incumbent is required to not have facial hair that interferes with a tight seal of the respirator.
• Performs other duties as required.
• Frequent local travel.

Job Specification:

• Current Social Work licensure in the Commonwealth of Massachusetts at the Masters level (L.I.C.S.W. or L.C.S.W.) required
• Minimum of 1 experience in Social Work providing traditional Clinical or Case Management services with a geriatric population
• Current C. P. R. Certification or ability to become certified
• Treat all participants in a welcoming and professional manner
• Strong verbal, written and listening skills with ability to multi-task in a fast pace environment

Compensation details:

69000-97000 Yearly Salary