Social Worker, MSW
4 months ago
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.
Assessment and Care Planning
- Performs initial assessments of participants to obtain a psychosocial history including cognitive status, mental health and substance use history, behavioral concerns, family dynamics, and current social supports.
- Participates within the interdisciplinary team in the formulation of Plans of Care for InnovAge program participants, as well as in other interdisciplinary team settings that plan, coordinate and monitor the care of InnovAge program participants.
- Conducts in-person reassessments of enrolled participants every six months or as determined by policy and best practice. Assessments include collaboration with caregivers and assessment of housing risk.
- 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.
- Develops a collaborative relationships with internal and external partners. Utilizes a solution-oriented perspective to facilitate resolution of participant needs.
- Acts as a primary liaison between the participant/family and the IDT to facilitate communication.
- Facilitates, mediates and documents participant care conferences, family meetings and facility partnership meetings.
- Actively and assertively manages respite and hospital length of stay (applicable for non-Pennsylvania locations). Collaborates with participants, caregivers, facilities and the IDT to ensure clear communication regarding participant status and plan.
- Works in collaboration with hospital discharge planners, primary care, IDT, families and caregivers regarding participant's disposition from the hospital. Partners with the InnovAge Mental Health Team when hospitalization is psychiatric.
- Provides referrals to and coordinates assessments with contracted facilities. Supports the participants in the tour and move planning process as clinically indicated.
- Completes Pre-Admission Screen and Resident Review (PASSR) for all nursing home admissions from the community.
- Partners with the InnovAge Medicaid Department to assist the participant in keeping resources within the guidelines of Medicaid eligibility and supports the recertification process.
- Advises the participant or financially responsible party about housing co-pays and for non-Pennsylvania locations, may be responsible for notifying the Medicaid department of the need to generate a Supportive Housing Form.
- Actively participates in the completion of ROIs, ULTC 100.2s and other paperwork needed to provide care (applicable for non-Pennsylvania locations).
- Supports the inter-center transfer process for participants who move between catchment areas, relaying participant history and care plan issues to the receiving social worker.
- Provides referral support to community resources and participates in inter-agency coordination of care.
- Proactively supports the participant grievance process, involving the Center Director in all potential voluntary disenrollments due to dissatisfaction.
- Assists participants who are disenrolling with transition to outside services, including timely referral back to the single entry point and completion of disenrollment paperwork.
- Maintains accurate and timely documentation and paperwork including participants' electronic medical records according to policies and procedures.
- Attends and actively participates in IDT meetings, Social Services department meetings, Cross Sites and Annual Competencies.
- Provides on-call support after hours as assigned, if applicable.
- Monitors changes in the patient's condition and needs.
- 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.
- Evaluates quality of psychosocial services provided and adjusts interventions as clinically indicated.
- Schedules home visits as necessary according to patient needs.
- 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.
- Strive for continuous growth and development of Cultural Competency exhibiting an understanding, awareness, and respect for diversity.
- Provides caseload coverage support as assigned for MSW PTO, open FTEs, and general team needs.
- Performs other duties as assigned.
- Master's degree from a school of social work accredited by the Council on Social Work Education
- Current CPR certification or the ability to obtain CPR certification is required.
- One year experience in a health care setting working with the frail and elderly
- Experience conducting psychosocial assessments, care planning and case management skills required.
- Require personal transportation, current state issued driver's license, good driving record and auto insurance as required by law.
- 3+ years social work experience
Benefits
InnovAge is dedicated to empowering seniors to live independently, allowing them to age in their own homes and communities safely. InnovAge offers an alternative to nursing homes through its Program of All-inclusive Care for the Elderly (PACE), which provides enrolled seniors with customized healthcare and social support at PACE Adult Day Health Centers. These centers are staffed by medical professionals who are committed to creating personalized care plans for each participant. At InnovAge, our team members are our greatest asset and have a significant impact on the lives of our participants every day. When you join InnovAge, you'll work alongside talented, respectful, and passionate colleagues within a patient-centered care model.
InnovAge is committed to equal opportunity and affirmative action, and we strive to create a diverse and inclusive workplace. We consider all qualified candidates for employment without discrimination based on race, color, religion, sex, sexual orientation, gender identity/expression, national origin, disability, protected veteran status, pregnancy, or any other protected status. Salaries are determined by various factors such as qualifications, experience, and location, and do not include potential bonuses or benefits. Our extensive benefits package includes medical/dental/vision insurance, short and long-term disability, life insurance and AD&D, supplemental life insurance, flexible spending accounts, 401(k) savings, paid time off, and company-paid holidays.
Applicants are considered until the position is filled.
Posted Salary Range
USD $73,000.00 - USD $89,000.00 /Yr.
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