• Determines participant needs including psychosocial, physical and mental health, financial, and environmental issues by completing in-depth psychosocial assessment.
• Based on findings developes and initiates a participant -centered service plan consistent with program guidelines.
• Cultivates relationships and partnerships with community providers that support and extend social work interventions.
• Facilitates the enrollment of participants with the assistance of the On Lok enrollment specialist.
• Establishes and maintains a care management relationship with participants and their significant others as appropriate, offering respect, dignity and support.
• Provides crisis intervention, advocacy, problem solving and appropriate therapeutic interventions.
• Acts as the primary advocate within the interdisciplinary setting and within community programs related to ongoing management of mental health, co-occurring substance abuse issues, and chronic issues of unstable housing.
• Consistent with program guidelines, meets regularly with participants to review progress on plan of care goals and modifies as needed.
• Documents via EHR service delivery notes, all care management activity regarding identified problems within 24 hours and in compliance with program requirements.
• Liaisons between the medical department and participant regarding promoting and documenting discussions on end of life, health care wishes, and coordinating advance health care planning.
• Maintains required paperwork and follows a clear, concise, and consistent system of charting to allow for continuity of care.
• Educates particpants and significant others about resources and when possible, trains them to manage their own needs.
• Establishes and maintains open and effective communication with IDT and other community providers. Provides appropriate information on all significant aspects of individual participant care and program operations, while maintaining necessary confidentiality.
• Working closely with other disciplines, continuously evaluates and promotes the participants' ability to remain safely in current home environment; coordinates placement as appropriate and within program guidelines.
• Participates in research studies and data collection, as required.
• Attends and actively participates in interdisciplinary team and program meetings, activities and problem-solving endeavors; contributes to open lines of comunication within the team.
• Utilizes supervision appropriately; maintaining open lines of communication and providing updates on caseload activity.
• Understands and applies the regulatory and procedural requirements of the social work discipline within PACE as well as the policies and procedures of the Institute on Aging.
• Attends continuing education classes and/or inservice training to increase knowledge, skills and attitudes related to case management, gerontology, family and community systems and other areas relevant to the Institute on Aging participant population.
• Participates in and promotes ongoing efforts towards Continuous Quality Improvement and Utilization Review.
• Actively incorporates the ethical standards of the National Association of Social Workers into all aspects of interactions with others.
• All other reasonably related responsibilities as assigned.

EDUCATION:

M.S.W. (Masters in Social Work) degree required; LCSW preferred. Supervision towards licensure provided.

BACKGROUND AND EXPERIENCE:

• One year working with disabled adults and/or older adults required.
• Fluent in Cantonese, Mandarin or Spanish preferred
• Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and older adults.
• Experience working with individuals with mental and/or behavioral health diagnoses and substance abuse disorders highly desired.
• Exceptional communication and presentation skills relating to functionally impaired adults and older adults, their support systems and teams of health professionals.
• Demonstrates case management skills and experience in the community health care delivery system.
• Detail oriented with good problem solving skills and the ability to prioritize multiple tasks.
• Computer literacy required.

COMPENSATION:

• Range:$34.96 -$41.99/hr