Master Social Worker-Lycoming

Overview
We are seeking a dedicated and compassionate Master Social Worker to join our team. He or she will provide social work services including advocating, assessing, assisting, collaborating, educating, evaluating, implementing, and planning for participants in various aspects of the participant's life including but not limited to psychological, psychosocial, financial, environmental, and interpersonal matters. Social work engagement takes place in various settings, including but not limited to the participant's home, PACE site, and community settings (hospital, SNF, ALF, etc.). The Social Worker will assess and evaluate psychosocial functioning, conduct mental status assessments, participate in discharge planning, and enlist collateral community agencies’ services as applicable.

Duties

• Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations and 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 will be reported to the IDT and documented.
• Ensure telephonic outreach is made within 24-48 hours of hospitalization and regularly thereafter during admission to provide support to the participant, coordinate with the hospital clinical team to discuss the participant's treatment plan and assist in discharge plan coordination with the PACE IDT.
• Complete biopsychosocial assessments (initial, semi-annual, and periodic reassessments), cognitive/emotional status assessments (i.e., GDS, SPMSQ), and other assessments as applicable. Assist with completion of healthcare proxy documents in coordination with primary care and nursing.
• Facilitate psycho-educational presentations for the participants in the day health centers. Presentations will be for educational purposes and to promote the social worker’s role in the IDT.
• 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 appropriate social work interventions and recommendations. Ensure social work interventions are applied, and participant-centered goals are met.
• Represent the Social Work Department and Kinship Health at appropriate meetings and conferences in the community.

Requirements

• Master’s degree in Social Work from an accredited program required.
• One (1) year of experience in a healthcare setting with a frail or elderly population is required.
• Experience in patient care, intake processes, and case management.
• Familiarity with medical documentation standards and medical records management.
• Excellent communication skills, both verbal and written.
• Ability to work effectively with individuals from diverse backgrounds and varying ages, particularly in geriatrics.
• Knowledge of aging issues counseling is preferred but not mandatory.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Work Location: In person