Job Summary

Under the direction of the social work manager, responsible for direct social work case

management services to participants.

Essential Job Functions

• Participate as a member of the interdisciplinary team (IDT), conduct initial, semi-annual,
• unscheduled, and annual assessments; attend morning updates and report changes in participants’
• baseline status to appropriate staff on a daily basis.
• Involved in the development and implementation of QI activities.
• In conjunction with the IDT, may conduct the initial intake, meeting with family members and others. Coordinate ongoing family meetings, as needed.
• Obtain extensive social history from participant and/or family member upon admission to program.
• Provide individual and family counseling as needed or prescribed in the plan of care; develop and lead group counseling and support activities.
• Provide crisis intervention and advocacy as required.
• In conjunction with the interdisciplinary team, coordinate discharge planning for participants returning home from hospital or nursing facility.
• Maintain current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and participant’s expressed wishes.
• Act as liaison between the participant and other agencies such as Department of Aging,
• Social Security Administration, Medicaid, etc.
• Assist with money management.
• Assist with ongoing financial eligibility for participants, including recertification as needed.
• Participate in participant-related conferences in the community as designated.
• Maintain confidentiality of participant information.
• Attend and participate in staff meetings, in-services, projects, and committees as assigned.
• Adhere to and support the company’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
• Be flexible in schedule of hours worked.
• May require use of personal vehicle.
• Working Conditions and Physical Demands
• The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Ability to access all areas of the center throughout the workday.
• Ability to lift up to 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly;
• required to obtain assistance of another qualified employee when attempting to lift or transfer objects over 25 pounds.
• Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling.
• Ability to communicate verbally with an excellent comprehension of the English language.
• Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and airconditioned environment.

Experience

• Minimum of one (1) year of documented experience in working with the frail or elderly population required.
• Prefer experience in a community-based setting or geriatric program.
• Experience in substance abuse counseling
• Experience in working with the homeless population
• Knowledge, Skills, and Abilities
• Interest in the risk-based long-term care program to serve frail elderly in a community-based setting.
• Experience and thorough knowledge of social service principles and practices.
• Knowledge of psychosocial, behavioral, and family needs of the elderly population.
• Knowledge of financing mechanisms such as Medicare, Medicaid, and Prospective Payment Systems.
• Knowledge of the local and social service delivery systems and aging network.
• Proven ability to work in an interdisciplinary team.
• Ability to work effectively and harmoniously with the staff, the elderly, and providers of services, public, and private agencies.
• Energetic, dependable, resourceful, and flexible.
• Effective oral and written communication skills.
• Computer skills required.

Education and Certification

• Master’s degree in social work required.
• Is medically cleared for communicable diseases and has all immunizations up to date before
• engaging in direct participant contact.