Social Services Coordinator

2 days ago


Modesto, California, United States Integrated Resources, Inc.;InterSources, Inc. Full time
Job Summary

The Social Worker is a vital member of the Interdisciplinary Team (IDT) at Integrated Resources, Inc.;InterSources, Inc. This role is responsible for managing a caseload of participants, providing psychosocial assessments, care planning, counseling, and case management services. The Social Worker will work closely with the IDT, participants, their families, and other stakeholders to promote the organization's values, team culture, and mission.

Key Responsibilities
  • Conduct social work assessments to determine the psychosocial needs, preferences, and goals of participants and participate in IDT meetings to develop participant care plans.
  • Deliver and document social work interventions as agreed upon in the participants' care plans, including arranging necessary resources and services, assisting with care transitions, providing individual and group counseling, and case management.
  • Work with the PACE Physician and other members of the IDT to support smooth care transitions between settings, such as hospitals, skilled nursing facilities, and home.
  • Remain alert to pertinent input from other team members, participants, and caregivers and update the IDT promptly of any changes in participants' condition or psychosocial status.
  • Facilitate enrollment of prospective participants into the program, coordinate care conference meetings, and ensure the highest level of care coordination among PACE IDT members, participants, and other people within the participants' support network.
  • Provide discharge planning when participants disenroll from the program, educational in-services to staff, participants, and caregivers/families regarding psychosocial aspects of aging and related issues, and participate in end-of-life care coordination and support.
  • Conduct home visits, as necessary, and provide support with Medi-Cal and Medicare enrollments to benefits eligibility staff.
  • Must have reliable transportation to travel to participants' homes within assigned territory and be legally authorized to perform in position location.
Requirements
  • Minimum of one year of experience with a frail or elderly population.
  • Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and interdisciplinary team members.
  • Experience coordinating and facilitating care conference meetings, facilitating problem-solving with challenging psychosocial and family situations, and highly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situations.
  • Excellent organizational and communication skills, ability to work independently with minimal supervision, demonstrated ability to prioritize in a fast-paced environment, experience and competency working with people from diverse backgrounds and cultures, and commitment to unlocking the full potential of our most vulnerable seniors.


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