Master Social Worker

Job summary

Assesses the psycho-Social needs, provides of participants and advises the interdisciplinary team and his/Her colleagues on the development and implementation of participant care plans. Provides social services support, case management, counseling and referrals to external agencies.

Job responsibilities

• Serves on the PACE interdisciplinary team (IDT).
• Performs assessments, scheduled reassessments and unscheduled reassessments of participant’s history, personal and family circumstances, home environment, psycho-social status and cognition.
• Collaborates with other members of the IDT to develop participant plans of care.
• Refers participants to community agencies or facilities, acting as a liaison and advocating for participants to obtain services for which they are eligible.
• Communicates changes in participant status to interdisciplinary team members and notes changes in the plans of care.
• Helps participants cope with physical, social, emotional and psychological problems or disabilities.
• Helps participants understand and navigate Medical eligibility issues, tracking eligibility renewals and assisting with this process.
• Helps participants apply for social security disability and Medicare coverage as needed.
• Helps participants find better or alternative places to live, when appropriate.
• Helps participants maintain basic social supports so they remain safe, warm, and dry.
• Advises colleagues about ways to meet participants’ social service needs.
• Develops and leads group sessions for cognitive stimulation and emotional health.
• Assists the clinical team with discharge planning and transitions of care, when necessary.
• Assists in the management of homebound participants and those at risk for caregiver stress through regular visits and telephone contact.
• Participates in family conferences, team meetings, committees and work groups as required.
• Participates in policy development and revision for the social work component of the program.
• Participates in the coordination ofa 24-hour care delivery system.
• Participates in the Quality Improvement program