Essential Functions:

* Assesses participants/family psychosocial status and social work needs utilizing professional; knowledge skills of observations and interviewing skills.
* Assesses a member's living condition/situation, cultural influences, and support systems to identify member's strengths and deficits.
* Assesses a member's need for daily money management annually and as needed.
* Develops and implements the social work components and works with other team members to develop a comprehensive interdisciplinary team plan of care based on the needs of participants and caregivers, and goals mutually acceptable to the member/family and significant others.
* Monitors effectiveness and outcomes regularly and keeps the team informed as to participants' progress and level of need. Remains alert to pertinent input from other team members, participants and family members/caregivers. Reviews and revises goals and approaches to member/family care in coordination with interdisciplinary team members.
* Provides initial face-to-face psychosocial assessments of new members enrolled in the program, and face-to-face reassessments at appropriate intervals according to PACE standards and the individual needs of each participant.
* Provides ongoing assessments and services to identified family participants, including emotional support reassurance, assistance with community resource planning and crisis intervention.
* Coordinates with the entitlement coordinator to ensure the entitlements and benefits are unplace and recertified annually.
* Provides advocacy to members/family., assistance in obtaining entitlements and community services.
* Coordinates with the Primary Care team on obtaining advanced directives, educates members of the family on the right to develop advanced directives which may include Health Care Proxy, Living Will, DNT, MOLST, Durable Power of Attorney and or Burial Plans.
* Educates and assesses participants/family understanding and ability to pay their Medicaid surplus payment, as appropriate.
* Documents change un the participant's conditions and details are provided by completing all required PACE documentation and ensuring compliance with Agency standards and policies.
* Travels to patients' homes and other facilities with varying environments as needed.
* Manages social work planning for a caseload of participants. Maintains productivity sufficient to meet program goals.
* Assists the interdisciplinary team members, including the physician, as appropriate, in understanding the significant social and emotional factors related to the members' health problems.
* Utilizes appropriate community resources and serves as a liaison between the program and other community agencies.
* Provides social work services in accordance with agency policies, practices and procedures.
* Assumes responsibility for continued professional growth, such as in0service programs.
* Participates in selected programs with community agencies.
* Regularly informs the interdisciplinary team of the medical, functional and psychosocial condition of each participant.
* Remains alert to pertinent input from other team members, participants and caregivers.
* Documents change of a participant's condition in the participant's medical record consistent with documentation policies established by the medical director participate in Pace and ARCHCARE SENIOR LIFE meetings including but not limited to, interdisciplinary team meetings, family meetings, in service and training programs, rehab service meetings and quality improvement activities.
* Maintains flexibility in schedule and responds to unexpected emergencies and changes in workload in order to fulfill responsibilities.
* Perform other related duties, as required.
* Meet a standardized set of competencies for the specific position description established by PACE organization and approved by CMS before working independently.