The position is responsible for the direct social work care management services, such as participant screening, case management, counseling and referral, to the participants of the CalOptima PACE program.
POSITION RESPONSIBILITIES:
- Participates in the Interdisciplinary Team’s initial, 6 month, and annual assessments, care planning of the participant's case in accordance with industry and departmental standards.
- Documents participant changes appropriately in the medical record in accordance with industry and departmental standards.
- Communicates effectively and openly with other Interdisciplinary Team members on participant status and needs.
- Assesses for high risk situations such as suicidal/homicidal ideation and abuse. Reports appropriately in accordance with legal and ethical standards of practice and engages in safety planning with participant and/or family.
- Develops and leads group counseling and participant support group activities.
- Refers participants and families to appropriate community agencies or facilities, serves as a liaison with such organizations, and as an advocate for participants.
- Assists in the completion of advance directives, mortuary arrangements, funeral planning, and/or facility placement.
- Provides assistance to patient(s)/representative(s) in ascertaining third party and financial resources and planning for financial coverage for services, as necessary.
- Consults with and advises staff members in regard to the relationship of social, emotional and cultural factors to health and medical care, and as to the availability of social services in the community.
- Attends and participates in in-services, staff meetings, and case conferences.
- Helps support new enrollee process of enrollment into the PACE program (i.e. communicates to IDT and ensures all gaps of service are covered prior to enrollment).
- Addressess any psychosocial needs that may require social work support and intervention (i.e. anxiety, depression, and behaviors) both at center and at home.
- Works with PACE participant and the interdisciplinary team in developing an appropriate discharge plan for disenrolling from PACE services.
- Participates in program improvement to social work department.
- Involvement with QI department to support grievances, appeals, and advocacy consistent with participant’s rights.
- May be required to perform home visits to private homes of CalOptima PACE participants; frequent travel in Orange County.
- Other projects and duties as assigned.
Required Skills
- Work effectively in a team environment.
- Communicate effectively and have interpersonal and conflict resolution skills.
- Only act within the scope of his/her authority to practice.
- Analytical thinking and problem solving skills.
- Meet a standardized set of competencies for the specific position description established by CalOptima PACE and approved by regulatory agencies before working independently.
- Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
- Pass a criminal background which will verify that the candidate is: not excluded from participation in Medicare and Medicaid programs; has not been convicted of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act; and have not been convicted of physical, sexual, drug or alcohol abuse.
- Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, Outlook, PowerPoint) and job-specific applications/systems.
Required Experience
EXPERIENCE & EDUCATION:
- Master’s degree in Social Work from an accredited college or university required.
- 2 years’ experience in a health-related area required.
- 1-year experience working with the frail or elderly population. Relevant experience must be within the last 3 years required.
- Minimum 1 year of case management experience with the frail or elderly population preferred.
- Valid California Driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record is required.
- Bilingual in English and in one of CalOptima's defined threshold language (Spanish) is preferred.
KNOWLEDGE OF:
- Individual therapy (psycho-social) techniques for geriatric participants.
- Clinical knowledge of assessments and social work interventions.
Grade: K
#CB