Job Description

Summary

Reporting to the Social Work Manager, the Social Worker maintains a caseload of participants working in close coordination with the IDT. In addition to delivering standard social work services such as psychosocial assessments, care planning, counseling and case management, the Social Worker functions as a liaison between the participants, family members, support network and care team, as appropriate.

Essential Job Duties:

• Conduct Social Work assessments to determine the psychosocial needs, preferences and goals of the participants and actively participate in IDT meetings to develop participant care plans
• Deliver and document social work interventions as agreed upon in the participants’ care plans including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual as well as group counseling and case management
• Work with the primary care physician and other members of the care team to guide smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home, etc.)
• Initiate, coordinate and facilitate care conference meetings to ensure the highest level of care coordination among other care team members, participants, and other people within the participants’ support network (family, informal caregivers etc.)
• Provide discharge planning when participants disenroll from the program

Job Requirements:

• Master’s Degree in Social Work (MSW) required
• Minimum of one (1) year of experience with a frail or elderly population
• Previous experience coordinating and facilitating care conference meetings
• Previous experience assisting people with behavioral health & substance abuse issues, preferred

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