Work Type: Per diem/PRN – dayshift, M-F hours only

Compensation: $40/hour

What is PACE?

PACE, or Program of All-Inclusive Care for the Elderly, is an alternative care model for those over 55 years of age requiring nursing home level of care which aims to keep participants living at home in the community. PACE is a collaborative, interdisciplinary approach which coordinates all levels of medical and social needs, including prevention, wellness, socialization, primary care, and access to specialists and other services.

The Social Worker provides and coordinates a wide range of psychosocial services to participants and their families. The Social Worker is also responsible for providing community-based case management services for program participants.

Primary Duties and Responsibilities:

• Conducts an initial Social Work assessment and scheduled and as-needed reassessments for all PACE participants.?
• May participate in completion of Determination of Need (DON) document as part of PACE enrollment eligibility assessment.
• Performs all functions and duties as required as a member of the PACE Interdisciplinary Team (IDT), including, but not limited to, participation in IDT meetings, family conferences, grievances, service determination requests, CMS audits.
• Coordinates with IDT in developing individualized plans of care for each PACE participant.
• Performs comprehensive psychosocial assessments in accordance with practice act: for the evaluation, treatment, and prevention of mental and emotional disorders in individuals, families, and groups based on knowledge and theory of professionally accepted theoretical structures, including, but not limited to, psychosocial development, behavior, psychopathology, unconscious motivation, interpersonal relationships, and environmental stress.
• Establishes and maintains a working rapport with participants.
• Maintains and promotes patient satisfaction through acknowledgement that environmental, social, and cultural factors influence one’s health.
• Assures completion of assessments in appropriate time frame
• Identifies warning signs of mental health distress, communicates findings with IDT, makes recommendations to behavioral health counselors or other professionals as needed.
• Monitors the quality and effectiveness of the services provided to a participant according to the individualized care plan.
• Maintains documentation in a timely and complete manner and according to program standards and policies.
• Refers participants to appropriate community agencies or facilities and acts as a liaison with such organizations as an advocate for participants.
• Facilitates understanding of psychosocial aspects of care and provides the IDT with behaviorally stated psychosocial objectives.
• Consults and collaborates with other professionals to promote quality and continuity of participant care.
• Demonstrates creative critical thinking in problem-solving patient/family issues.
• Participates in Quality Improvement activities as requested.
• Assist participants with care and transportation as assigned.
• Performs other duties as assigned.

• Strong demonstrated capabilities in networking with community resources and strong knowledge of such resources
• Strong communication skills, including face-to-face, telephone, and computer skills.
• Strength in attention to detail and organization
• Must be able to interact successfully with participants, families, and other agencies to present a positive and professional image.
• Ability to manage multiple priorities simultaneously and effectively handle the emotional stress of the workload.
• Ability to work unsupervised exercising a high degree of discretion & independent judgment.
• Ability to physically access any home, hospital, nursing home, and ALF i.e., navigate stairs, narrow stairs, narrow spaces, lack of air conditioning, etc.
• Ability to travel within PACE service area.
• Bilingual (preferred).
• Master’s degree or above in Social Work required.
• Two (2) years’ experience working in a medical or behavioral health social work capacity preferred.
• One (1) year of experience minimum working with the frail elderly required.
• Licensed Social Worker in the state of Illinois (LSW).
• Must be certified in CPR/BLS (Basic Life Support) by the American Heart Association.
• Must possess valid driver’s license and documentation of current automobile insurance at PACE organization-specified levels.

Esperanza Health Centers is an Equal Opportunity Employer (EOE) according to Title 44, Ill. Administrative Code, and Subpart C Section 750.150.