Provide ongoing casework services to members and their authorized representatives to help them understand accept
and follow care recommendations, to assist them with personal and environmental difficulties which predispose
toward illness or interfere with obtaining maximum benefit from the PACE program.
Educate members and their authorized representatives in understanding and using community health and welfare
resources which help them remain safely in the community (EBT, SCRIE, DRIE, Medicaid, etc.)
The Social Worker will ensure timely and appropriate coordination of care, before, during and after hospitalization or
other inpatient stay to ensure that a member's wishes regarding his/her care are followed during that period. Develop
discharge plans and ensure that the services the member requires are in place in order to facilitate a timely and safe
discharge and ensure that the members will be cared for at home.
Ensure that when a member is hospitalized a visit is made within 24-48 hours. To provide support to the member,
meet the hospital clinical team to discuss member's treatment plan and to begin to coordinate the discharge plan.
The Social Worker will coordinate the discharge with the PACE staff (reinstating PCW service, transportation
coordination with the discharge planner, follow up with the SNF, and other vendors as needed, etc.) The Social
Worker will also conduct a visit to the member within 24-48 hours of discharge.
JOB DESCRIPTION
Provides social work consultation to members and authorized representatives as indicated and requested. Provide
education on treatment options and help coordinate services. Arrange bereavement assistance, supportive counseling
or other mental health services. The Social Worker is responsible for the completion of psychosocial, mental status
tools assessment, MOLST, GDS (when applicable), and other tools as appropriate,
Completing comprehensive assessments via the McKesson, Care Compass, Epaces, and other systems as needed.
Organizes workload to insure appropriate and maximum social services to members and authorized representatives.
Use case management skills to help members and families address and resolve social, financial, psychological
problems related to the member's health.
The Social Worker is responsible for integrating best social work practices into the total care of the patient by
collaborating with other professional personnel within CenterLight Healthcare, in acute care institutions, skilled
nursing facilities and other community agencies.
Participates in interdisciplinary member care conferences, team and family meetings. Responsible for quarterly,
annual, significant change assessments, ensuring documentation is completed timely and accurately.
Maintains detailed and up-to-date records on every member and submit daily reports of his/her activities to the Social
Work Manager / designee.
Participates in appropriate continuing education programs sponsored by the Social Work Department, CenterLight
Healthcare and applicable outside agencies. Participate in staff enhancement through professional knowledge by
attending approved seminars/workshops relevant to the field of Social Work.
Participates in peer supervision conferences and individual conferences with the Social Work Manager / designee.
Represents the Social Work Department and CenterLight Health System at appropriate meeting and conferences in
the community.
All other duties as assigned by Supervisor.
