Social Worker (MSW) – PACE

Talent-Connect-Now; Los Angeles (CA); On-site; USD 60,000 - 90,000; Full time

Job summary

Talent Connect Executive Search & HR Solutions is recruiting a Social Worker for a healthcare organization operating Programs of All-Inclusive Care for the Elderly (PACE). The role focuses on psychosocial support, care coordination, and advocacy for older adults with complex needs.

As part of an interdisciplinary team, you will help participants and families address emotional, social, and practical challenges that affect well-being and community living.

Qualifications

• MSW from an accredited university.
• Strong psychosocial assessment, care planning, and resource coordination skills.
• Ability to support older adults and families navigating complex healthcare and social service needs.
• Strong communication, documentation, and problem-solving skills.
• Ability to collaborate effectively with a multidisciplinary healthcare team.
• Commitment to respectful, culturally responsive, participant-centered care.

Responsibilities

• Complete psychosocial assessments and evaluate support systems, caregiver needs, safety concerns, and barriers to care.
• Develop and implement individualized social work interventions aligned with care plans.
• Provide counseling and education to participants and caregivers on adjustment to illness and caregiver stress.
• Connect participants with community resources, benefits assistance, caregiver support, and behavioral health services.
• Participate in IDT meetings and communicate psychosocial concerns to monitor progress.
• Collaborate with clinical staff to support care transitions after hospitalization or changes at home.
• Facilitate advance care planning discussions and refer to appropriate resources.
• Assist with discharge or disenrollment coordination to ensure continuity of care.
• Recognize and report concerns involving abuse, neglect, or safety as required.
• Maintain accurate documentation of assessments, interventions, referrals, and outcomes.
• Coordinate referrals when specialized clinical support is needed.

Skills

Psychosocial assessment

Care planning

Resource coordination

Communication skills

Documentation skills

Interdisciplinary collaboration

Cultural sensitivity

Bilingual English/Spanish

Education

MSW from an accredited university

Tools

Electronic Health Records (EHR)

Job description

Talent Connect Executive Search & HR Solutions is recruiting aSocial Worker on behalf of a healthcare organization providing Programs of All-Inclusive Care for the Elderly (PACE).

The Social Worker will provide psychosocial support, care coordination, and advocacy for older adults with complex medical and social needs. As a member of the interdisciplinary team (IDT), this professional will help participants and families address emotional, social, and practical challenges that affect well-being and the ability to remain safely in the community.

Key Responsibilities

• Complete initial, periodic, and change-in-condition psychosocial assessments, evaluating support systems, coping skills, caregiver needs, safety concerns, and barriers to care.
• Develop and implement individualized social work interventions aligned with participant preferences and comprehensive care plans.
• Provide supportive counseling and education to participants and caregivers regarding adjustment to illness, changes in independence, grief, and caregiver stress.
• Connect participants and families with community resources, benefits assistance, caregiver support, and appropriate behavioral health services.
• Participate in IDT meetings, communicate psychosocial concerns, and evaluate progress toward care plan goals.
• Collaborate with clinical staff and community providers to support care transitions following hospitalizations or changes in living arrangements.
• Facilitate advance care planning discussions and connect participants with appropriate resources and team members.
• Assist with discharge or disenrollment coordination, supporting continuity of care and access to needed services.
• Recognize and respond to concerns involving abuse, neglect, exploitation, or participant safety according to organizational procedures and applicable reporting requirements.
• Maintain accurate, timely documentation of assessments, interventions, referrals, and participant outcomes.
• Provide services within professional scope and coordinate referrals when participants require specialized clinical support.

Required Qualifications

• Master of Social Work (MSW) from an accredited university.
• Strong psychosocial assessment, care planning, and resource coordination skills.
• Ability to support older adults and families navigating complex healthcare and social service needs.
• Strong communication, documentation, and problem-solving skills.
• Ability to collaborate effectively with a multidisciplinary healthcare team.
• Commitment to respectful, culturally responsive, participant-centered care.

Preferred Qualifications

• Current California Licensed Clinical Social Worker (LCSW) license.
• Experience in PACE, geriatric care, healthcare case management, home health, or long-term care.
• Experience providing supportive counseling, caregiver education, and crisis support.
• Familiarity with community resources and benefits programs serving older adults in Southern California.
• Bilingual English/Spanish skills.
• Experience with electronic health records and interdisciplinary care planning.

Work Environment and Schedule

This position supports an onsite, community-based PACE program. Responsibilities may include services in the PACE center, participants’ homes, or other assigned settings based on program needs.

The assigned location, work schedule, employment arrangement, compensation, benefits, and any additional certification requirements will be discussed during the interview process.