Social Worker, MSW

InnovAge; California (MO); On-site; USD 55,000 - 77,000; Full time

Job summary

InnovAge is seeking an MSW to deliver on-site social work services at our center and in field settings, supporting participants and caregivers across care transitions.

The role includes comprehensive psychosocial assessments, care planning, discharge planning, and strong collaboration with the interdisciplinary team to ensure coordinated, quality care in line with InnovAge policies and regulatory requirements.

Responsibilities

• Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
• Completes in-person reassessments at least every six months or as required.
• Performs in-home visits as required by regulations or as indicated
• Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
• Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
• Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined.
• Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.
• Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
• Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
• Documents housing encounters in EPIC
• Collaborate with comfort care team for end-of-life activities
• Assists participant’s family with end-of-life coordination
• Collaborates with RN Case Management on hospitalizations, and provides psychosocial input
• May serve as back-up to RNCM.
• Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate.
• Coordinates guardianship process for participants lacking decision‑making capacity without a surrogate.
• Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported.
• Provides options counseling when appropriate
• Assists participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork.

Job description

Job Description

Job Description

Responsibilities

The Social Worker, MSW plans, organizes and implements social work services to participants and their caregivers in accordance with InnovAge policies and all applicable regulations. Conducts psychosocial assessments, participates in care planning and acts as a liaison between the participant and the interdisciplinary team.

This role requires being on-site at the center and field-based work, including visits to participants’ homes and other locations, to ensure continuity of care and support.

Essential Functions and Work Responsibilities

Functional Category: Assessment & Care Planning

• Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
• Completes in-person reassessments at least every six months or as required.
• Performs in-home visits as required by regulations or as indicated
• Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
• Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
• Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined.
• Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.

Functional Category: Case Management & Care Coordination

• Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
• Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
• Documents housing encounters in EPIC
• Collaborate with comfort care team for end-of-life activities
• Assists participant’s family with end-of-life coordination
• Collaborates with RN Case Management on hospitalizations, and provides psychosocial input
• May serve as back-up to RNCM.
• Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate.
• Coordinates guardianship process for participants lacking decision‑making capacity without a surrogate.
• Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported.
• Provides options counseling when appropriate
• Assists participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork.

Functional Category: Psychosocial Support & Advocacy

• Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated
• Completes comfort care assessments and provides guidance on transitions to end‑of‑life services.
• Advocates for participants living in unsafe housing conditions
• Contributed to RCAs development, incident reporting, and follow‑up for abuse, neglect, exploitation, and elopements.
• Assists participants and caregivers with grievances and appeals, explaining rights and processes.
• Provides notification and explanation of participant rights regarding Level of Care (LOC) denials or disenrollment declines.

Functional Category: Documentation & Compliance

• Maintains accurate and timely documentation in Epic, EireneRx, and other systems (demographic updates, address/phone changes, participant chart updates).
• Complete PASSR screenings, supportive housing forms and other like documents as mandated by federal and state agencies within regulatory timelines.
• Supports Medicaid eligibility recertification processes,
• Partners with Eligibility Financial Determination teams to educate participants/families on required information/documentation needed to maintain and restore Medicaid eligibility
• dictation, and assists with resource compliance.
• Accurate and timely reporting of disenrollments in required systems
• Escalates to Center Director service recovery is needed for a participant concern or disenrollment
• Ensures all participant care coordination complies with CMS, HCPF, and InnovAge policy requirements.

Functional Category: Professional Development & Team Collaboration

• Participates in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies.
• Provides community education and participates in external support groups, inter‑agency coordination, and partnership meetings with RCFEs as indicat