Senior Services Social Worker

About the Role

This position offers a unique opportunity to help build the first PACE (Program of All-Inclusive Care for the Elderly) program in the State of Illinois within a supportive, innovative, and expert leadership team. The PACE Social Worker is responsible for planning, organizing, and implementing social work services to LCHC PACE participants and families, reporting to the LCHC PACE Clinical Services Director.

Responsibilities

• Conduct initial, 6-month, change-of-condition, and annual assessments, presenting them at care plan conferences to develop the Plan of Care and facilitate team discussions.
• Act as liaison between participants, caregivers, and the interdisciplinary team, day center, and other LCHC PACE services, including volunteers.
• Provide ongoing support and education to participants and families on aging, dementia, grief, end-of-life care, disease processes, family dynamics, and role changes.
• Maintain participant housing through proactive intervention with participants, caregivers, and housing providers to ensure the highest level of independent community living.
• Coordinate admissions and discharges to contracted facilities for respite and permanent placement.
• Initiate nursing home co-pay status for permanent skilled facility placements as directed by the team and supervisor.
• Perform home visits to assess living environments and support systems.
• Provide referrals and assessments for personal care boarding homes and assisted living residences.
• Facilitate participant moves between residences or assisted care facilities when no other support systems are available.
• Coordinate hospital discharges in collaboration with attending medical team members.
• Initiate referrals to external resources, such as Adult Protective Services, Housing Authority, or public utility companies.
• Assist participants and caregivers with completing POA, Proxy, and DNR directives.
• Help participants set up and maintain personal needs accounts.
• Maintain current documentation in medical records, including assessments, reassessments, change-of-status notes, placements, hospital discharges, and significant events.
• Assist participants with SSI and SSDI applications as needed.
• Refer potential voluntary disenrollments due to dissatisfaction to the PACE leadership team and complete internal disenrollment and death forms.
• Assist participants and families in coordination with the LCHC PACE Outreach Department to maintain Medicaid eligibility.
• Serve as a required member of the Interdisciplinary Team, attending daily IDT meetings.
• Perform other tasks as assigned.

Requirements

• Master’s Degree in Social Work.
• Licensed Social Worker in good standing in Illinois (LCSW preferred).
• Must pass a pre-employment screening and criminal background check.
• Current Driver’s License and valid automobile insurance.
• OIG background check performed prior to employment.

Skills

• Commitment to upholding the mission of Lawndale Christian Health Center.
• Ability to work independently, take initiative, and set priorities aligned with clinic needs.
• Personal integrity demonstrated through punctuality, honesty, teamwork, attention to detail, and willingness to learn.
• Clear and concise written and verbal communication skills for professional interactions with patients and coworkers.
• Ability to prioritize and manage multiple tasks in a dynamic environment.
• Flexibility to adapt to changing or stressful conditions, including schedule adjustments.
• Ability to use interpreters or Spanish-speaking technicians when necessary.
• Strong background in patient counseling and interpersonal skills, with experience working across diverse ages, cultures, and backgrounds.

Spanish language skills are helpful.