Social Worker - On Lok PACE Program
Overview
Social Worker leads case management for On Lok participants delivering home care and community services. This role drives independent judgment through psychosocial assessments and care planning while collaborating with interdisciplinary teams. Unique opportunity to shape senior care solutions within a supportive nonprofit environment.
What You'll Do11
- 1Conduct initial and routine psychosocial assessments to develop individualized care plans
- 2Partner with caregivers to create and deliver comprehensive service plans
- 3Identify psychosocial risks and coordinate referrals for specialized community resources
- 4Provide individual counseling and facilitate family conferences
- 5Develop discharge planning for participants exiting the program
- 6Lead caregiver groups and participate in community outreach events
- 7Act as primary liaison between participants, families, and external agencies
- 8Maintain accurate documentation following PACE and healthcare regulations
- 9Participate in quality improvement initiatives using Healthcare Hospitality G.R.E.A.T. Practices
- 10Support team meetings and advocate for participant needs
- 11Implement electronic health record systems and manage clinical documentation
Requirements9
- 1MSW degree with minimum one-year experience working with frail elderly populations
- 2Minimum one-year case management experience with preference for healthcare settings
- 3Proven ability to work independently and collaborate within interdisciplinary teams
- 4Strong organizational skills with demonstrated capacity for multitasking
- 5Experience with electronic health records preferred
- 6Minimum one-year experience in healthcare-related environments
- 7Minimum one-year experience managing participant care transitions
- 8Bilingual communication skills beneficial for diverse client populations
- 9Ability to thrive in fast-paced, dynamic settings with minimal supervision
Salary Insight
$94 - $125k per year
Location
Required Skills
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