PACE Social Worker

About Us Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together. Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community. As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants. ROLE OVERVIEW and PURPOSE The Social Worker will manage a caseload of participants by providing a psychosocial perspective to the interdisciplinary evaluation, assessment, plan of care, ongoing services, and disenrollment processes of the PACE program at Neighborhood Healthcare. This role will collaborate with the interdisciplinary team to optimize the health status and quality of life of Neighborhood PACE participants. Additionally, this role will liaise between participants, members of participants’ support network, and the interdisciplinary team. This is a full-time-onsite. Schedule: Monday-Friday, 8:00 am-5:00 pm. Responsibilities Works with the PACE Interdisciplinary Team (IDT) to conduct initial, semi-annual, unscheduled, and annual assessments Provides participant health status updates to appropriate staff in daily meetings Obtains extensive psychosocial history from participants and/or family members upon admission to program and intermittently at pre-enrollment Coordinates, schedules, and facilitates family conferences in conjunction with the PACE IDT to address levels of care, medication/treatment non-compliance, out-of-home placement, complex diagnoses, behavioral concerns and contracts, conditions of involuntary disenrollment, and alternative program options Develops and facilitates various group counseling topics designed to assist at-risk populations over the age of 55 with chronic health conditions Provides individual caregiver and family support counseling, as needed Coordinates with participants, family/caregivers, and primary care providers to complete advance life planning documents, assist with end-of-life planning, and provide educational resources Conducts independent risk and safety assessments at skilled nursing facilities, residential care facilities for the elderly, assisted living facilities with/without memory care units, hospitals, and in-home, as needed Screens and develops share of cost for out-of-home placements based on financial documentation from participants and family members Creates and executes supportive housing forms with care facilities and family members, Conducts intermittent and annual income reviews to update supportive housing forms and share of costs Schedules, coordinates, and accompanies participants and family members with transportation and admission to higher level of care to promote safety and continuity of care in cases of high acuity Implements hospice and palliative care services by providing referral documentation, coordination, education, and support to participants and families Communicates with hospitals/skilled nursing facilities and utilizes external medical records systems to coordinate tailored discharge planning for participants Assists with ongoing financial eligibility for participants, including Medi-Cal recertifications, as needed Liaises effective connections and communications with other organizations in the eldercare field Provides support and education to staff members in areas of social, emotional, and cultural factors in the participant population, including how these factors relate to health, medical care, and the availability of social services in the community Schedules, coordinates, and conducts in-home visits and assessments independently and in conjunction with the PACE IDT, as needed Provides redirection and support for participants with behavioral needs during PACE Day Center attendance, utilization of PACE transportation, and use of other PACE services Refers participants and families to appropriate community agencies and facilities while acting as an advocate and liaison with such organizations Conducts discharge planning to promote continuity of care in the event of disenrollment Maintains federally compliant and timely documentation of institutionalizations, Adult Protection Service reports/follow-ups and consultations, community contacts, family conferences, assessments, and other case management notes in medical records Attends required staff meetings/trainings and voluntary professional development courses Qualifications Education/Experience Master’s degree in social work required One year of experience working with the elderly population required One year of social work experience preferred Experience working in a community-based setting or geriatric program preferred Current Basic Life Support (BLS) certification required upon hire and must be maintained as a condition of employment. These courses must follow AHA guidelines- may be completed through approved online providers such as ProMed or other equivalent programs that meet recognized BLS standards. In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually Bilingual (English/Spanish) preferred Additional Qualifications (Knowledge, Skills, and Abilities) Excellent verbal and written communication skills, including superior composition, typing and proofreading skills Ability to interpret a variety of instructions in written, oral, diagram, or schedule form Knowledgeable about and experience with counseling theories and techniques Knowledgeable about and experience with community resources for individuals and families Ability to establish and maintain good interpersonal relationships Ability to successfully manage multiple tasks simultaneously Excellent planning and organizational ability Ability to work as part of a team as well as independently Ability to work with highly confidential information in a professional and ethical manner Physical Requirements Ability to lift/carry 10 lbs/weight Ability to stand for long periods of time COMPLIANCE (Safety & HIPAA) Follows all safety procedures as outlined in Neighborhood Healthcare’s Illness and Injury Prevention Plan (IIPP) and report any injuries and/or unsafe conditions immediately Maintains current knowledge of policies and procedures as they relate to safe work practices Uses appropriate body mechanics to ensure an injury free environment Familiarity with location of nearest fire extinguisher and emergency exits Follows all infection control procedures including blood-borne pathogen protocols Maintains privacy of all patients, employee and volunteer information and access such information only on a need-to-know basis for business purposes Complies with all regulations regarding corporate integrity and security obligations Reports all behavior and/or activity that are unethical, fraudulent, or unlawful Neighborhood Healthcare offers a generous benefit plan that includes: Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more! Pay range: $80,200-$115,500 annually, depending on experience. Compensation Disclosure: The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to: the candidate’s overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.