CenterLight Health System is hiring: SOCIAL WORKER in New York

Overview

Under the direction of the Social Work Manager, the Social Worker will provide social work services including advocating, assessing, assisting, collaborating, educating, evaluating, implementing and planning for participants in various aspects of the participant's life including but not limited to psychological, psychosocial, financial, environmental, and interpersonal matters. Engagement takes place in settings such as the participant's home, PACE site, and community settings (hospital, SNF, ALF, etc.). The Social Worker serves as a conduit among the participant/authorized representative, the Interdisciplinary Care Team and other community agencies to ensure satisfaction throughout the PACE lifecycle. Support includes concrete services, adjustment to illness/disability/treatment, crisis intervention, and end of life care. Assessments include psychosocial functioning, mental status, discharge planning, and enlisting collateral community services as applicable.

Responsibilities

• Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations; assist with personal and environmental challenges relevant to the PACE program.
• Educate participants and authorized representatives in understanding and using community, health and public services and benefits (e.g., SNAP, SC/DRIE, Medicaid, Medicare, housing) and assist with referrals, coordinating services and related documentation as needed.
• Ensure timely and appropriate communication and coordination of care during/post hospitalization or inpatient stay; communicate with facilities/hospital/STR to ensure participant wishes are followed during admission; report to the IDT and document.
• Conduct telephonic outreach within 24-48 hours of hospitalization and regularly thereafter; coordinate with the hospital clinical team to discuss treatment plans and assist in discharge planning with the PACE IDT. Visit the participant within 72 hours of discharge to assess psychosocial issues.
• Provide social work consultation, education on treatment options including palliative and end-of-life care, coordinate services, arrange bereavement or other behavioral health services, and provide caregiver support as needed.
• Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, ROC, SCIC, SDR), cognitive/emotional status assessments (e.g., GDS, SPMSQ) and other applicable assessments; complete HCP document and facilitate advance directives (e.g., DNR/DNI/DNH/MOLST).
• Care plan development and implementation focusing on psychosocial goals and interventions; ensure documentation is completed timely and accurately; utilize EMR as needed.
• Organize and manage workload to provide maximized social services; use case management and clinical skills to address social, financial, and psychological problems related to health; ensure timely coordination of care and services.
• Collaborate with CenterLight Healthcare and other professionals across acute care, skilled nursing facilities, and community agencies to integrate best practices into total care.
• Facilitate psycho-educational presentations for participants in day health centers and participate in IDT/care plan meetings; document social work concerns and interventions; ensure goals are met.
• Engage in continuing education, professional training, peer supervision, and community representation as requested.
• Ensure acting within scope of authority and meet competency standards established by the PACE organization before working independently.
• Other duties as assigned by supervisor.

Schedule & Hours

Schedule: 9:00 AM – 5:00 PM

Weekly Hours: 35

Qualifications

• Education: M.S.W. from an accredited college or university.
• Experience: One (1) year of experience in a healthcare setting. Minimum of one (1) year of experience with a frail or elderly population; if less than one year, must receive appropriate training from the PACE organization. Experience in home care and/or field work is preferred. Regular access to a car for field visits is preferred but not required.
• License: LMSW or LCSW required. Active NY State Social Work license.
• Additional Requirements: Be legally authorized to practice in the state; be medically cleared for communicable diseases and up-to-date immunizations before direct participant contact.
• Physical Requirements: Ability to perform job duties including standing, sitting, lifting up to 50 pounds, bending, stairs, walking between sites, and other physical demands as described; requires travel between sites.

Compensation & Benefits

Salary Range (Min-Max): $82,000.00 - $99,000.00

Note: Position wages are contingent upon terms and conditions outlined in the collective bargaining agreement.

Additional Information

• Affirmative action and equal opportunity employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information.
• We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities.

Job Details

• Seniority level: Entry level
• Employment type: Full-time
• Job function: Other
• Industries: Hospitals and Health Care