Social Worker, MSW
Location: San Bernardino
Posted on: September 20, 2022
The Social Worker plans, organizes and implements social work
services to participants and their caregivers in accordance with
InnovAge policies and all applicable regulations. Conducts
psychosocial assessments, participates in care planning and acts as
a liaison between the participant and the interdisciplinary
Assessment and Care Planning
* Performs initial assessments of PACE participants to obtain a
psychosocial history including cognitive status, mental health and
substance use history, behavioral concerns, family dynamics, and
current social supports.
* Participates within the interdisciplinary team in the formulation
of Plans of Care for InnovAge PACE program participants, as well as
in other interdisciplinary team settings that plan, coordinate and
monitor the care of InnovAge PACE program participants.
* Conducts in-person reassessments of enrolled participants every
six months or as determined by policy and best practice.
Assessments include collaboration with caregivers and assessment of
* Completes home visits at least annually and as needed to work
proactively with participant, IDT, and community partners to
maintain the participant's functioning as independently as possible
in their community.
* Develops a collaborative relationship with internal and external
partners. Utilizes a solution-oriented perspective to facilitate
resolution of participant needs.
* Acts as a primary liaison between the participant/family and the
IDT to facilitate communication.
* Facilitates, mediates, and documents participant care
conferences, family meetings and facility partnership meetings.
* Actively and assertively manages respite and hospital length of
stay. Collaborates with participants, caregivers, facilities, and
the IDT to ensure clear communication regarding participant status
* Works in collaboration with hospital discharge planners, primary
care, IDT, families, and caregivers regarding participant's
disposition from the hospital. Partners with the InnovAge Mental
Health Team when hospitalization is psychiatric.
* Provides referrals to and coordinates assessments with contracted
facilities. Supports the participants in the tour and move planning
process as clinically indicated.
* Completes Pre-Admission Screen and Resident Review (PASSR) for
all nursing home admissions from the community.
* Partners with the Innovage Medicaid Department to assist the
participant in keeping resources within the guidelines of Medicaid
eligibility and supports the recertification process.
* Advises the participant or financially responsible party about
housing co-pays and notifies the Medicaid department of the need to
generate a Supportive Housing Form.
* Actively participates in the completion of ROIs, ULTC 100.2s and
other paperwork needed to provide care.
* Supports the inter-center transfer process for participants who
move between catchment areas, relaying participant history and care
plan issues to the receiving social worker.
* Provides referral support to community resources and participates
in inter-agency coordination of care.
* Proactively supports the participant grievance process, involving
the Center Director in all potential voluntary disenrollments due
* Assists participants who are disenrolling with transition to
outside services, including timely referral back to the single
entry point and completion of disenrollment paperwork.
* Maintains accurate and timely documentation and paperwork
including participants' electronic medical records according to
policies and procedures.
* Attends and actively participates in IDT meetings, Social
Services department meetings, Cross Sites and Annual
* Provides on-call support after hours as assigned.
* Monitors changes in the patient's condition and needs.
* Assists physician, or intermediate care provider, and other team
members in understanding the significant social and emotional
factors related to the health problems.
* Provides psychosocial services in accordance with established
* Evaluates quality of psychosocial services provided and adjusts
interventions as clinically indicated.
* Schedules home visits as necessary according to patient
* Acts as a resource to other team members and staff regarding
topics such as dementia, difficult behaviors, and difficult
personalities. Supports the IDT in establishing behavior management
* Strive for continuous growth and development of Cultural
Competency exhibiting an understanding, awareness, and respect for
* Provides caseload coverage support as assigned for MSW PTO, open
FTEs, and general team needs.
* Performs other duties as assigned.
* Master's degree from a school of social work accredited by the
Council on Social Work Education
* 1+ year experience in a health care setting
* Experience conducting psychosocial assessments, care planning and
case management skills required
* Require personal transportation, current state issued driver's
license, good driving record and auto insurance as required by
* A minimum of one year experience working with the frail or
* 3+ years social work experience preferred
Job Title: Social Worker
FLSA Exemption Status: Exempt
Reports to: Social Services Manager
Keywords: InnovAge, San Bernardino , Social Worker, MSW, Healthcare , San Bernardino, California
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