Who We Are

Are you interested in working for an organization whose mission is to enable frail, underserved, and multicultural senior communities to live independently at home and in their communities, for as long as possible?

Fresno Program of All-Inclusive Care for the Elderly (PACE) is dedicated to providing its participants with comprehensive health and social supports that are proven to effectively manage chronic conditions and to reduce the risk for premature institutionalization. PACE staff are leaders in the “aging in place” industry and we have had the honor of serving Fresno, Bakersfield and Orange County seniors and their families/caregivers.

Job Summary

• Under the direction of the social work manager, responsible for direct social work case management services to participants.

Essential Job Functions

Participate as a member of the interdisciplinary team (IDT), conduct initial, semi-annual, unscheduled, and annual assessments; attend morning updates and report changes in participants’ baseline status to appropriate staff on a daily basis.

• Involved in the development and implementation of QI activities.
• In conjunction with the IDT, may conduct the initial intake, meeting with family members and others. Coordinate ongoing family

meetings, as needed.

• Obtain extensive social history from participant and/or family member upon admission to program.
• Provide individual and family counseling as needed or prescribed in the plan of care; develop and lead group counseling and

support activities.

• Provide crisis intervention 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, reassessment of

changing needs and participant’s expressed wishes.

• Act as liaison between the participant and other agencies such as Department of Aging, Social Security Administration,

Medicaid, etc.

• Assist with money management.
• Assist with ongoing financial eligibility for participants, including recertification as needed.
• Participate in participant-related conferences in the community as designated.
• Maintain confidentiality of participant information.
• Attend and participate in staff meetings, in-services, projects, and committees as assigned.
• Adhere to and support the company’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.

Working Conditions and Physical Demands

The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• 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

• Minimum of one (1) year of documented experience in working with the frail or elderly population required.
• Prefer experience in a community-based setting or geriatric program.
• Experience in substance abuse counseling
• Experience in working with the homeless population

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.

Education and Certification

• Master’s degree in social work required.
• Is medically cleared for communicable diseases and has all immunizations up to date before engaging in direct participant

contact.

Core Values

• Respect at the core of our interactions.
• Honesty and Integrity with every endeavor
• Patient – Centered care aligned with participant values, beliefs, and preferences.
• Encouragement that motivates and empowers others to be the best they can be.
• Quality Care that is efficient, transformative and innovative.