Social Services Coordinator

2 days ago

Pasadena, California, United States Integrated Resources Full time
Job Summary

The Client Social Worker is a vital member of the Integrated Resources team, responsible for managing a caseload of participants in close coordination with the Client Interdisciplinary Team (IDT). This role requires excellent clinical, organizational, and communication skills to deliver standard social work services, including psychosocial assessments, care planning, counseling, and case management.

Key Responsibilities
  • Conduct thorough social work assessments to determine the psychosocial needs, preferences, and goals of participants and actively 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.
  • Collaborate with the PACE Physician and other IDT members 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 in coordination with the Intake team.
  • Initiate, coordinate, and facilitate care conference meetings to ensure the highest level of care coordination among PACE IDT members.
  • Provide discharge planning when participants disenroll from the program.
  • Offer educational in-services to staff, participants, and caregivers/families regarding psychosocial aspects of aging and related issues.
  • Participate in end-of-life care coordination and support.
  • Conduct home visits, as necessary.
  • Provide support with Medi-Cal and Medicare enrollments to benefits eligibility staff.
  • Must have reliable transportation to travel to participants' homes within assigned territory.
Requirements
  • Minimum of one year of experience working 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.
  • Ability to facilitate problem-solving with challenging psychosocial and family situations.
  • 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.
  • Commitment to unlocking the full potential of our most vulnerable seniors.
Preferred Qualifications
  • Experience supporting individuals with behavioral health and substance abuse issues.

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