JOB SUMMARY:
The Social Worker (MSW) provides direct social work and care management services to participants of the PACE program, offering comprehensive support to enhance their quality of life and ability to live independently in the community. Responsibilities include participant screening, case management, counseling, and referrals, as well as planning, organizing, and implementing social work services tailored to participants and their families. 

As a liaison between the interdisciplinary team, caregivers, and community agencies, the Social Worker ensures participant needs are effectively addressed, and services are coordinated seamlessly. This role is essential in promoting participant well-being, advocating for their needs, and advancing the mission and goals of the PACE program. 

ESSENTIAL DUTIES AND RESPONSIBILITIES: 

• Participate in initial assessments, care planning, and periodic reassessments (at least every six months) of participant cases, ensuring assessments are completed prior to team meetings and adhere to departmental standards.
• Document participant changes and updates in the medical record accurately and in compliance with industry and departmental standards.
• Collaborate and communicate effectively with Interdisciplinary Team (IDT) members regarding participant status, needs, and care plans.
• Maintain up-to-date case management records, including periodic participant reassessments, and ensure comprehensive documentation.
• Coordinate 24-hour care delivery and provide individual and family counseling to support participants and caregivers.
• Develop and facilitate group counseling sessions and activities to address participant needs.
• Refer participants and families to appropriate community resources, acting as a liaison and advocate to ensure access to needed services.
• Foster effective relationships among team members, promoting team building and cohesion.
• Consult with staff on the impact of social, emotional, and cultural factors on participant health, and advise on available social services in the community.
• Participate in program and policy development for social work services and contribute to Quality Improvement (QI) processes.
• Conduct home visits to participants’ private residences to evaluate and support their needs.
• Actively participate in IDT meetings and contribute to care planning and team discussions.
• **NJ: Social work services which fall within the scope of practice defined by the Social Workers' Licensing Act of 1991 (N.J.S.A. 45:15BB-1 et seq.) and the New Jersey State Board of Social Work Examiners shall be provided by a social worker.
• Perform additional duties and special projects as assigned.

EXPERIENCE AND EDUCATION: 

• Bilingual with fluency in Hmong.
• Master’s degree in social work from an accredited school of social work accredited by the Council on Social Work Education.
• Member of the Academy of Certified Social Workers (ACSW) or other NASW-recognized certification preferred. 
• Current License in the required state. 
• Two (2) years of experience working on an interdisciplinary team in a hospital, nursing home, or community-based setting is preferable. 
• 1 year of experience working with a frail or elderly population preferred. If this is not present, training will be provided upon hiring. 

**NJ: Each social worker shall be certified or licensed by the New Jersey State Board of Social Work Examiners and shall comply with the Social Workers' Licensing Act of 1991 (N.J.S.A. 45:15BB-1 et seq.) and amendments thereto and with all rules of the New Jersey State Board of Social Work Examiners. 

PRE-EMPLOYMENT REQUIREMENTS: 

• Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.    
• Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.    
• Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.