Social Worker

Job Title: Social Worker

FLSA Exemption Status: Exempt

State/Business Line Specific: PACE

Reports to: Center Manager

Supervises: N/A

Job Summary

The Social Worker plans, organizes and implements social work services to participants and their caregivers in accordance with InnovAge policies and all applicable regulations. Conducts psychosocial assessments, participates in care planning and acts as a liaison between the participant and the interdisciplinary team.

Essential Functions and Work Responsibilities

Functional Category: Client Care
Estimated Percent of time Spent – 100%

• Assists physician, or intermediate care provider, and other team members in understanding the significant social and emotional factors related to the health problems.
• Provides psychosocial services in accordance with established standards.
• Participates in the coordination of Agency's services with the services of other community resources; uses community resources.
• Participates in discharge planning.
• Serves as a resource person to employees, patients, physicians and other allied healthcare providers.
• Develops a cooperative relationship and communicates effectively and professionally with physicians.
• Immediately reports any accident, incident, lost articles or unusual occurrence to appropriate management staff
• Participates in staff meetings and patient care conferences as scheduled.
• Maintains contact with community support groups and provides professional expertise as required.
• Participates in the development of the plan of care; ensures that the patient plan of care includes identified problems, interventions and goals.
• Participates in community activities and facilitates community awareness and support; promotes awareness of services
• Evaluates quality of psychosocial services provided.
• Monitors changes in the patient's condition and needs.
• Schedules patient visits as necessary according to patient needs and as physician orders.
• Acts as a resource to other team members and staff regarding topics such as dementia, difficult behaviors, and difficult personalities. Supports the IDT in establishing behavior management plans.
• Maintains accurate and timely documentation and paperwork including participants’ electronic medical records according to policies and procedures
• Attends and actively participates in a variety of organizational meetings related to participant care or daily operations.
• Attends and actively participates in Social Work specific department meetings, Cross Sites and Annual Competencies.
• Maintains accurate and timely service utilization data.
• Facilitates, mediates and documents participant care conferences/family meetings when there is a need for a problem solving, team meeting in order to clarify or update the InnovAge plan of care.
• Assists participants and caregivers in filing grievances or appeals when a dissatisfaction or break in service occurs according to InnovAge policies and procedures.
• Participates in continuing education to support professional development and stay current with developing trends in providing competent social work services to older adults.
• Completes home visits at least annually, and as needed to work proactively with participant, IDT, and community partners to maintain the participant’s functioning as independently as possible in their community.
• Presents requests to IDT and participates in the coordination of admission/discharge to contracted facilities for temporary respites and permanent placement.
• Completes Pre-Admission Screen and Resident Review (PASSR) for all nursing home admissions from the community.
• Actively manages respite length of stays, collaborating with the ppt, caregivers and IDT.
• Attends care conferences at contracted facilities as appropriate.
• Provides referrals to and coordinates assessments with contracted facilities which may involve; completing applications, furnishing medical records, accompanying participants to interview assessments and tours.
• Supports participants in making arrangements, as needed, who are moving between residences or care facilities and have no support system available to assist.
• Participate in transfers between center IDT’s for participants who move between catchment areas. Collaborates with the social worker of the receiving team in order to share participant history and care plan issues.
• Assists participants and caregivers to set up and maintain Personal Needs Accounts when requested.
• Conducts in person reassessments of enrolled participants every six months, or as needed. Assessments include collaboration with caregivers and assessment of housing risk.
• Performs initial assessments of PACE participants to obtain a psycho-social history, including; cognitive status, mental health and substance use history, behavioral concerns, family dynamics, and current social supports.
• Works in collaboration with hospital discharge planners, primary care, IDT, families and caregivers regarding participant’s disposition from the hospital.
• Refers potential voluntary disenrollments due to dissatisfaction to Center Director; assists participants who are disenrolling with transition to outside services which includes a timely referral back to the single entry point and submission of disenrollment paperwork.
• Participates within the interdisciplinary team in the formulation of Plans of Care for InnovAge PACE program participants, as well as in other interdisciplinary team settings that plan, coordinate and monitor the care of InnovAge PACE program participants.
• Performs other duties as assigned.

Travel Requirements

Travel

• Travel may be required
• Overnight travel may include local or out of state

Relocation

• Must be open to relocation based on business necessity

Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

REQUIRED

Education

• Master’s degree from a school of social work accredited by the Council on Social Work Education

Licensure, Certification, Registration or Designation

• Require personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law.
• NM and CA: Current State LMSW, LCSW or LISW certification
• Current CPR certification or the ability to obtain CPR certification is required.

Work Experience and Qualifications

• One year experience in a health care setting
• Experience conducting psychosocial assessments, care planning and case management skills required.
• A minimum of one year experience working with the frail or elderly.

PREFERRED

Work Experience and Qualifications

• Three to five years social work experience
• Bi-lingual preferred
  
  Other Knowledge Skills and Abilities Required
  
  Computer Skills
  
  • Must be computer proficient and possess experience with Microsoft Word, Excel, and Outlook.
  • Must be able to quickly learn specific software and new applications.
  
  Mathematical/Financial Skills
  
  • Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
  • Able to analyze data and statistics and draw reasonable conclusions and compile accurate reports.
  • Experience with P/L and developing and managing budgets.
  
  Language Skills
  
  • Ability to read, analyze and interpret regulations and other documents.
  • Strong interpersonal skills and ability to effectively and tactfully present information to, and communicate with, co-workers, employees, and others.
  • Possess exceptional English written and verbal communication skills, including accurate grammar and business correspondence knowledge.
  • Ability to read and write memos, reports, and correspondence that conform to prescribed style and format.
  
  Reasoning Ability
  
  • Ability to define problems, collects data, establish facts, and draw valid conclusions.
  
  Other Skills and Abilities:
  
  • Able to establish and maintain cooperative and positive working relationships.
  • Organized, detail-oriented, diplomatic, proactive, self-motivated, dependable, and driven by excellence.
  • Even-tempered and able to balance multiple tasks in accordance with changing deadlines and priorities in a fast-paced environment.
  • Ability to work sensitively and effectively with individuals of diverse ethnic and cultural backgrounds.
  
  InnovAge Service Standards Requirements
  Safety
  
  • Safety- Maintains a safe work place. Reports all unsafe work conditions to supervisor and/or Safety & Loss Control Manager and works in conjunction with supervisor, Safety & Loss Control Manager, and staff to correct unsafe work conditions. Follows and enforces all safety policies.
  Accountability
  
  • Commitment – Commits to his/her job and to the success of the company. Continuously puts forth the effort to achieve goals and continuous quality improvement. Degree to which employee goes the extra step to ensure job/task completion. Takes initiative to offer ideas to improve processes or results.
  • Cooperativeness – Consistently supports management decisions as demonstrated by his/her actions. Demonstrates a “can do” attitude by responding positively to instructions. Follows instructions and works harmoniously with others to complete the job or task.
  • Attendance – Meets or exceeds punctuality and attendance expectations/requirements. Faithfully reports to work and conforms to scheduled work hours. When necessitated, follows call-in procedures and informs others of absences.
  Caring
  
  • Customer Service - Embraces the organization's commitment to internal and external customer service and demonstrates a customer-centric approach when interacting with co-workers, participants, clients, and all other business contacts.
  • Confidentiality – Maintains confidentiality of employee, participant, and client data/information, and any other sensitive organization information as appropriate.
  Integrity
  
  • Adherence to Company Policy – Follows and enforces guidelines as established by policies. Conforms to company and job standards and requirements. Shows respect for others. Acts in the best interests of the company at all times. Serves as an example for others. Conducts business in an ethical fashion.
  • Reliability – Completes responsibilities with minimal direct supervision. Follows through with assigned jobs and tasks all the way through completion. Puts forth the effort to achieve goals and objectives under varying circumstances.
  • Alignment with Company Goals & Objectives – Supports the organization’s mission, vision, and values and holding self-accountable for applying these principles daily and personally living them when working with co workers, participants, clients, and all other business contacts.
  Quality
  
  • Quantity of Work / Productivity – Produces at a high volume. Always puts forth the effort to maximize productivity. Meets or exceeds established work deadlines. Engages in a productive work effort whenever possible. Meets goals and objectives.
  • Quality of Work – Produces work that is accurate and reliable. Accomplishes work quickly and efficiently. Works in a thorough and organized manner while minimizing down time. Results are consistently within acceptable quality standards.
  • Job Knowledge – Demonstrates a thorough understanding of his/her job processes and procedures. Integrates knowledge to efficiently accomplish job requirements. Efficiently uses resources (including staff and management) to obtain additional knowledge.
  • Communication – Exhibits good interpersonal skills. Develops and fosters professional relationships with co-workers, participants, clients, and vendors. Keeps others informed as directed by operational demands and need-to-know. Keeps self informed of announcement made via established company venues
  
  Physical Demands /Work Environment
  
  PHYSICAL DEMANDS
  Must possess mobility to work in a standard office setting, or clinical setting, and use standard office equipment, including a computer, and medical equipment; vision/sight (close distance, long distance, depth and peripheral) to assess emergency situations, including medical incidents and to read printed materials and a computer screen; and hearing and speech to communicate in person, before groups, and over the telephone. Depending on assignment, standing in work areas and walking between work areas may be required, and travel to visit various cultural, physical, behavioral and environmental settings may be required. Finger dexterity is needed to access, enter, and retrieve data using a computer keyboard, typewriter keyboard, or calculator and to operate standard office and medical equipment. Positions in this classification occasionally bend, stoop, kneel, reach, push, and pull drawers open and closed to retrieve and file information. Employees must possess the ability to lift, carry, push, and pull materials and objects up to 50 pounds. Reasonable accommodations will be made for individuals on a case-by-case basis.
  
  WORKING CONDITIONS
  Employees primarily work in an office environment with moderate noise levels and controlled temperature. Employees may work outdoors and are occasionally exposed to loud noise levels and cold and/or hot temperatures. Incumbents may be exposed to blood and body fluids in the performance of their assigned duties. Employees may interact with members of the public or with staff under emotionally stressful conditions while interpreting and enforcing departmental policies and procedures.
  
  MATERIALS, TOOLS EQUIPMENT, WORK AIDS
  May require use of wheelchair, medical equipment, gait belts, sliding board, bedside commode, shower equipment, and other work aids
  
  STRESS FACTORS
  May require working under stressful conditions. May experience pressure to meet scheduled deadlines. There may be distractions such as phone calls, work interruptions, and communication from co-workers.
  Respond and intervene appropriately to multiple interruptions. Working conditions may be noisy and crowded and expose employee to fluctuating indoor temperatures, and humidity around showers/bathrooms.
  

40/week