Who We Are

To empower our senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support.

Benefits

• 401(k)
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

Job Summary
The Social Worker MSW is responsible for direct social work case management services to participants and works collaboratively with the PACE Interdisciplinary Team (IDT) to manage long-term care needs.

Essential Job Functions
Duties include, but not limited to:

• 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.
• Familiar with the California Adult Protective Services (APS) mandated reporting requirements and guidelines.
• Provide education regarding Durable Power of Attorney, Advance Health Care Directive
• Deliver psychoeducation regarding depression, assessment, and cognitive assessment results to participants and their family members.
• Involved in the development and implementation of Quality Improvement (QI) activities.
• In conjunction with the interdisciplinary team (IDT), may conduct the initial intake, meeting with family members and others. Coordinate ongoing family meetings, as needed.
• Obtain biopsychosocial history from participant and/or family members upon admission to the 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 IDT, 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.
• Provide resources and referrals to assist with financial 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 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 the schedule of hours worked.
• May be required to use personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required.

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 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.

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-lit, well-ventilated, heated, and air-conditioned environment.

Experience

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

Education and Certification

• Master’s degree in social work from an accredited school of social work.
• Is medically cleared for communicable diseases and has all immunizations up to date before engaging in direct participant contact.

Core Values

• CARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants.
• COMPASSION in every interaction, ensuring kindness, empathy, and understanding guide our care.
• CULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow.
• COMMUNITY that fosters connection, belonging, and support for participants and their families.
• COMMITMENT to quality improvement, innovation, and delivering healthier outcomes.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.