Social Worker

Responsibilities

• Participates on the IDT’s initial assessments, care planning and on-going re-assessments of participant care.
• Attends IDT meetings; actively participates in team meetings by sharing pertinent information, providing follow up to assigned tasks and helps to develop participant’s plan of care.
• Completes all assigned assessments – (initial, semi-annual, annual, service request and/or significant event).
• Affords psychosocial needs of the participant and provides supportive counseling, working collaboratively with behavioral health providers.
• Facilitates hospital, rehabilitation and nursing home (NH) admissions and discharges as determined by the Interdisciplinary Team.
• Ensures that PASRR documentation is completed for NH admission.
• Arranges and facilitates family meetings, as needed.
• Refers participants and families to appropriate community services and acts as liaison and/or advocate with community organizations for participants.
• Maintains professional, accurate and timely social service documentation in the participants’ medical records.
• Conducts participant council meetings as assigned.
• Works collaboratively with Director of Social Work and Behavioral Health provider to ensure guardianship is up to date.
• Educates participant regarding health care proxy (HCP).
• Assists participant in completion of HCP form.
• Works collaboratively with fiscal department to maintain participant insurance benefits and completes required documentation of fiscal information in the medical record.
• Reviews plan of care with participants, guardian, and/or activated health care proxy as assigned.
• Completes authorizations for home care and other approved services timely and accurately.
• Works collaboratively with Palliative care team; Assists with end of life planning as indicated.
• Provides timely communication to appropriate staff regarding the following: (disenrollment, conversion to long term care, transfer of sites, participant and/or caregiver demographic changes).
• Reports allegations of abuse to appropriate state agency; provides support and resources to participant as he/she will accept; completes required documentation.
• Absorbs ability to pass a fit test.
• Position requires mask where seal is critical.
• Incumbent is required to not have facial hair that interferes with a tight seal of the respirator.
• Performs other duties as required.
• Frequent local travel.

Qualifications

• Current Social Work licensure in the Commonwealth of Massachusetts at the Masters level (L.I.C.S.W. or L.C.S.W.) required.
• Minimum of 1 experience in Social Work providing traditional Clinical or Case Management services with a geriatric population.
• Current C. P. R. Certification or ability to become certified.
• Treat all participants in a welcoming and professional manner.
• Strong verbal, written and listening skills with ability to multi-task in a fast pace environment.
• Vietnamese and/or Khmer speaking but all MSW eligible candidates to apply.
• Covid vaccinated preferred.