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 like the participant's home, PACE site, hospitals, skilled nursing facilities (SNFs), assisted living facilities (ALFs), and other community settings.

The Social Worker serves as a liaison among the participant/authorized representative, the Interdisciplinary Care Team (IDT), and 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. The role involves assessing psychosocial functioning, conducting mental status assessments, participating in discharge planning, and coordinating with collateral community agencies.

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 communication and coordination of care during and after 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 the EMR for assessments and other systems, ensuring documentation is completed accurately and within 48 hours.
• Organize and manage workload to provide appropriate social services, using case management and clinical skills to address social, financial, and psychological issues related to the participant’s health.
• Integrate best practices into participant care by collaborating with professionals within CenterLight Healthcare, acute care institutions, SNFs, 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, and staff enhancement programs, including approved 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 only within the scope of authority to practice and meet standardized competencies for the role before working independently.
• Serve as an acting member of the IDT.
• Perform other duties as assigned by the supervisor.

Qualifications

Education: Master of Social Work (M.S.W.) from an accredited college or university.

Experience:

• One (1) year of experience in a health care setting.
• Minimum of one (1) year of experience working with a frail or elderly population. If less than one year, must receive training on working with this population upon hiring.
• Experience in home care and/or fieldwork is preferred.
• Regular access to a car for field visits is preferred but not required.

License: Active New York State Social Work license (LMSW or LCSW) required.

Additional Requirements:

• Legally authorized to practice in New York 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, following OSHA guidelines.
• Bending/Squatting: Required for patient care and medical supply use.
• 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: Ability to visually assess patients, read orders, and document accurately.
• Audio Hearing and Motor Skills: Ability to listen attentively, process audio information, and communicate clearly with participants, providers, and community members.
• Cognitive Ability: Must demonstrate good decision-making, reasoning, and analytical skills 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