About Job

JOB PURPOSE:

The Regional Home Care Social Worker will oversee and support the delivery of high-quality social work services to patients in various settings, such as, but not limited to clinics, home health, or outpatient services, under the direction of Director of Social Work.

These Social Work services include but are not limited to advocating, assessing, assisting, collaborating, educating, evaluating, implementing and planning for participants in various aspects of the participant's life. This also includes, but is not limited to, psychological, psychosocial, financial, environmental, and interpersonal matters.

This role involves the provision of Social Work services across multiple locations within a geographic region.

This role is responsible for monitoring and supporting the social work standards of excellence, working alongside with all departments and employees to support the audit and quality review process. The regional Home Care Social Worker will be responsible for making recommendations to the Director of Social Work regarding service delivery and documentation of services.

JOB RESPONSIBILITIES:

Direct Participant Care:

Conduct social work assessments.
Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations to assist them with personal and environmental challenges that predispose them toward illness or interfere with obtaining maximum benefit from the PACE program.
Educate participants and their authorized representatives in understanding and using community, health, and public services and benefits that help them remain safely in the community (SNAP, SC/DRIE, Medicaid, Medicare, housing, etc.) and assist with making referrals, coordinating services and completing related documents as needed.
Ensure timely and appropriate communication and coordination of care during/post hospitalization or other inpatient stays to ensure that a participant's wishes regarding his/her care are followed during that admission. All communication with facilities, hospitals/STR, will be reported to the IDT and documented.
Provide social work consultation to participants and authorized representatives as indicated. Provide education on treatment options, including palliative and end-of-life care, and help coordinate services. Arrange bereavement assistance, supportive counseling, or other behavioral health services as needed. Provide caregiver support as needed.
Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, CIS, SDR), cognitive/emotional status assessments (ie PHQ9, SPMSQ), and other assessments as applicable. Complete HCP documents and facilitate completion of advance directives, such as the DNR/DNI/DNH/MOLST documents.
Assure participant-focused Care Plan psychosocial goals and interventions are applied.
Utilize EMR for completion of assessments in a timely manner of 72 hours and other systems as needed.
Use case management and clinical skills to help participants and families address and resolve social, financial, and psychological problems related to the participant's health. Ensure timely and appropriate coordination and follow-through of care and services.
Act as a resource for the interdisciplinary team.
Collaborate with all members of the IDT in developing a comprehensive care plan based on member-specific needs, physician orders, UAS-NY CAPS, other IDT assessments, members’ specific parameters, and identified goals that are respectful of member, family, community, and agency resources.

Compliance and Quality Assurance:

Assist Director of Social Work in ensuring that all therapy services comply with state and federal regulations, accreditation standards, and company policies.
Assist Director of Social Work in monitoring and reviewing patient records, documentation, and progress reports to ensure accuracy and completeness.
Participate in quality improvement initiatives and audits to enhance patient care and operational efficiency.

Administrative Responsibilities:

Attend and actively participate in IDT and care plan meetings. Identify and document, as part of the care plan, and present social work-related concerns and/or issues and outline and discuss appropriate social work interventions and recommendations. Ensure and manage social work interventions are applied by social worker staff and participant-centered goals are met.
Represent the Social Work department and CenterLight at appropriate meetings and conferences in the community.
Participate in appropriate continuing education and professional training programs sponsored internally by CenterLight and/or applicable outside agencies. Participate in staff enhancement through professional knowledge by attending approved seminars/workshops relevant to the field of Social Work.
Participate in mandatory in-service education provided by CenterLight.
Ensure documentation is completed timely (within 24-72 hrs) and accurately.
Only act within the scope of the individual’s authority to practice.
Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.
Acting member of the IDT.

Other duties as assigned

Will provide supervision of Social Work services in clinic and field as necessary
Will provide orientation and clinical guidance to new team members as needed

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

QUALIFICATIONS:

Education: M.S.W. from an accredited college or university.

Experience:

Two (2) years of experience in a healthcare setting preferred.
Experience in home care, PACE setting, MLTC, and/or fieldwork is preferred.
Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.

License: Current active and unrestricted license and registration in NYS as a Social Worker, required.

Additional Requirements:

Vehicle and current New York State driver’s license preferred. Reliable Transportation is required.
Knowledge of New York State Department of Health Regulations.
Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function.
Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.
Work outside in varied weather conditions in all areas of the community, using private or public means of transportation.
Walk to and from patients’ homes.
Potential exposure to health hazards.
Work inside in well-lit, heated, and/or air-conditioned offices and/or in varied environmental conditions in the community, which includes participants' homes that the company may not be able to adjust for employee comfort.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

Standing – Duration of up to 6 hours a day.
Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely and using OSHA guidelines, etc.
Bending/Squatting – Must be able to safely bend or squat to care for patients, use medical supplies, etc.
Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas Position requires the individual to be able to travel, and walk between sites/locations and work areas throughout the day.
Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.)
Sight/Visual Requirements – Must be able to visually assess patients, read orders type/write documentation, etc. with accuracy.
Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

Job Type: Full-time

Pay: $105,000.00 - $110,000.00 per year

Benefits: