Social Worker

About the role

At WelbeHealth, each participant in the program is guided by an interdisciplinary team (IDT) composed of clinical and non‑clinical members who work together to provide comprehensive primary care and social services for frail seniors, enabling them to live safely in the community. Reporting to the Social Work Manager, the Social Worker maintains a caseload of participants and works in close coordination with the IDT.

In addition to standard social work services such as psychosocial assessments, care planning, counseling, and case management, the Social Worker serves as a liaison between participants, family members, support networks, and care teams as needed. Social Workers at WelbeHealth act as integral members of the IDT rather than working in isolation, collaborate with LCSWs on complex behavioral health issues, establish deep relationships with participants on their caseload, and help participants age safely and independently in their homes through community resourcing.

Responsibilities

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

Requirements

• Master’s degree in social work (MSW) required
• Minimum of one (1) year of experience working with a frail or elderly population preferred
• Experience coordinating and facilitating care conference meetings preferred
• Experience assisting people with behavioral health or substance abuse issues preferred
• Must obtain CPR and First Aid certification