Social Worker, MSW
4 days ago
Pueblo
Job Description Responsibilities The Social Worker, MSW 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 team. Essential Functions and Work Responsibilities Functional Category: Assessment & Care Planning • Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status)., • Completes in-person reassessments at least every six months or as required., • Performs in-home visits as required by regulations or as indicated, • Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care., • Facilitates and documents participant care conferences, family meetings, and facility partnership meetings., • Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined., • Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues., • Coordinates respite SNF, ALF admissions, including transportation and discharge planning., • Documents housing encounters in EPIC, • Collaborate with comfort care team for end-of-life activities, • Assists participant’s family with end-of-life coordination, • Collaborates with RN Case Management on hospitalizations, and provides psychosocial input, • May serve as back-up to RNCM., • Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate., • Coordinates guardianship process for participants lacking decision-making capacity without a surrogate., • Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported., • Provides options counseling when appropriate, • Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated, • Completes comfort care assessments and provides guidance on transitions to end-of-life services., • Advocates for participants living in unsafe housing conditions, • Contributed to RCAs development, incident reporting, and follow-up for abuse, neglect, exploitation, and elopements., • Assists participants and caregivers with grievances and appeals, explaining rights and processes., • Maintains accurate and timely documentation in Epic, EireneRx, and other systems (demographic updates, address/phone changes, participant chart updates)., • Complete PASSR screenings, supportive housing forms and other like documents as mandated by federal and state agencies within regulatory timelines., • Supports Medicaid eligibility recertification processes,, • Partners with Eligibility Financial Determination teams to educate participants/families on required information/documentation needed to maintain and restore Medicaid eligibility, • dictation, and assists with resource compliance., • Accurate and timely reporting of disenrollments in required systems, • Escalates to Center Director service recovery is needed for a participant concern or disenrollment, • Participates in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies., • Provides community education and participates in external support groups, inter-agency coordination, and partnership meetings with RCFEs as indicated, • Coordinates with facilities on participant needs. Travel Requirements Travel • Travel may be required To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions REQUIRED Education • Require personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law., • CPR/BLS and First Aid required in California only. Work Experience and Qualifications • One year experience in a health care setting, • Experience conducting psychosocial assessments, care planning and case management skills required., • Requires personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law. Work Experience and Qualifications • Three years or more of social work experience