SOCIAL WORKER

About the Role

The Social Worker provides social work services including advocating, assessing, assisting, collaborating, educating, evaluating, implementing, and planning for participants in various aspects of their lives such as psychological, psychosocial, financial, environmental, and interpersonal matters. Engagement occurs in settings including the participant's home, PACE site, and community settings (hospital, SNF, ALF, etc.). The Social Worker serves as a conduit among the participant/authorized representative, the Interdisciplinary Care Team (IDT), and other community agencies to ensure participant satisfaction throughout the PACE lifecycle. Responsibilities include providing support for concrete services, adjustment to illness/disability/treatment, crisis intervention, and end-of-life care.

Responsibilities

• Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations and assist with personal and environmental challenges.
• Educate participants and authorized representatives about community, health, and public services (e.g., SNAP, SC/DRIE, Medicaid, Medicare, housing) and assist with referrals, service coordination, and document completion.
• Ensure timely and appropriate communication and coordination of care during/post hospitalization or other inpatient stays, aligning with the participant’s care wishes. Report all communications to the IDT and document accordingly.
• Provide social work consultation, education on treatment options (including palliative and end-of-life care), and coordinate services such as bereavement assistance, supportive counseling, or behavioral health services. Offer caregiver support as needed.
• Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, SCIC, SDR), cognitive/emotional status assessments (e.g., PHQ9, SPMSQ), and other assessments. Complete HCP documents and facilitate advance directives (e.g., DNR/DNI/DNH/MOLST).
• Ensure participant-focused Care Plan psychosocial goals and interventions are applied.
• Utilize EMR for assessments and other systems, ensuring documentation is completed accurately and within 48 hours.
• Organize and manage workload to provide appropriate and maximized social services, using case management and clinical skills to address social, financial, and psychological problems.
• Integrate best practices into participant care by collaborating with professional personnel within CenterLight Healthcare, acute care institutions, skilled nursing facilities, and other community agencies.
• Facilitate psycho-educational presentations for participants in day health centers to promote the social worker’s role in the IDT.
• Attend and actively participate in IDT and care plan meetings, identifying, documenting, and presenting social work-related concerns, interventions, and recommendations.
• Participate in continuing education, professional training programs, and staff enhancement opportunities through seminars/workshops relevant to social work.
• Engage in peer supervision conferences and individual conferences with the Social Work Manager/designee.
• Represent the Social Work department and CenterLight Healthcare at community meetings and conferences.
• Act within the scope of authority to practice and meet standardized competencies for the position before working independently.
• Serve as an acting member of the IDT.
• Perform other duties as assigned by the supervisor.

Qualifications

• Education: M.S.W. from an accredited college or university.
• Experience: One (1) year in a health care setting. Minimum of one (1) year working with a frail or elderly population (or receive appropriate training if less than one year). Experience in home care and/or field work is preferred.
• License: LMSW or LCSW with an active NY State Social Work license.
• Additional Requirements: Legally authorized to practice in NY State. Medically cleared for communicable diseases with up-to-date immunizations before engaging in direct participant contact.

Physical Requirements

• Standing: Up to 6 hours a day.
• Sitting/Stationary: Up to 6-8 hours a day for consecutive periods.
• Lifting/Push/Pull: Up to 50 pounds of equipment, supplies, or patients safely using OSHA guidelines.
• Bending/Squatting: Required for patient care and use of medical supplies.
• Stairs/Steps/Walking/Climbing: Required to travel between sites/locations and work areas throughout the day.
• Agility/Fine Motor Skills: Required to operate equipment, devices, instruments, and tools (e.g., typing, medical supplies).
• Sight/Visual Requirements: Required for accurate patient assessment, reading orders, and documentation.
• Audio Hearing and Motor Skills: Required for accurate intake of information from patients, community members, and providers, and clear verbal communication.
• Cognitive Ability: Required for decision-making, reasoning, cognitive processing, and analysis to perform essential job functions.

Schedule

9:00 AM – 5:00 PM, Monday - Friday. Weekly Hours: 35.

Pay

Salary Range: $85,280.00 - $102,960.00.