Institute on Aging
Care Manager II Part-Time
Institute on Aging, San Francisco, California, United States, 94102
Medical Social Worker
IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the "status-quo" and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission. Primary Responsibility
The Medical Social Worker at On Lok PACE at the Institute on Aging (IOA) provides psychosocial assessment and therapeutic counseling to a caseload of clients with complex medical and psychosocial problems. The Medical Social Worker serves as the primary liaison between participants, family members, and the interdisciplinary care team. Specific Responsibilities
The specific responsibilities include: Conducts in-depth biopsychosocial assessments to determine participant needs across multiple domains. Utilizes evidence-informed interventions to solicit participant goals, and develops and initiates a participant-centered care plan. Joins Primary Care Providers and Registered Nurses to form a core primary care team for each participant. Develops a rapport and maintains a care management relationship with participants and members of their support system. Partners with the assigned Care Manager and other interdisciplinary team members to coordinate care for participants with complex needs. Provides supportive counseling to assist participants in coping with illness, grief, and loss. Facilitates family and care team meetings to ensure alignment and promote decision-making around end-of-life planning. Cultivates relationships and partnerships with community providers that support and extend social work interventions. Facilitates the enrollment of On Lok PACE participants at IOA in partnership with the On Lok PACE enrollment team. Fulfills an advocacy role, when necessary, within the interdisciplinary setting and within community programs. Facilitates behavioral health referrals and helps monitor efficacy of behavioral health interventions. Consistent with program guidelines, meets regularly with participants to review progress on plan of care goals. Documents all service delivery and encounters in the participant's electronic health record. Educates participants and their support system about available resources. Establishes and maintains open and effective communication with the interdisciplinary team and other involved community providers. Working closely with other disciplines and health professionals, continuously evaluates and promotes the participants' ability to remain safely in the community. Participates in quality improvement studies and data collection. Attends and actively participates in interdisciplinary team and program meetings. Recognizes clinical or personal limitations by utilizing supervision, when necessary. Understands and applies the regulatory and procedural requirements of the social work discipline within PACE. Remains current in the field of professional social work. Participates in and promotes ongoing efforts towards continuous quality improvement initiatives. Actively incorporates the ethical standards of the National Association of Social Workers. All other reasonably related responsibilities as assigned. Requirements
The requirements include: Must hold an MSW from an accredited school of Social Work. At least one year of professional experience working with frail elderly. At least one year of experience working in an interdisciplinary care model. Licensure is not required but supervision toward LCSW licensure is provided. Background and Experience
The background and experience include: Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly. Exceptional communication and presentation skills relating to the frail elderly, functionally impaired adults, their support systems, and teams of health professionals. Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks. Computer literacy preferred. Bilingual Cantonese, Spanish preferred. Compensation
The compensation range is $40.43 - $48.32. This amount is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any specific employee, which is always dependent on actual experience, education, and other factors. This range does not include any additional equity, benefits, or other non-monetary compensation which may be included.
IOA is on the forefront of revolutionary healthcare models, reshaping the way people can age in place. Our innovative models transform lives, enhance communities, and save healthcare systems millions of dollars. Rather than focusing on archaic outdated design, we strive to consistently question the "status-quo" and create new and more innovative ways to help aging adults and adults with disabilities maintain their quality of life. With over 23 programs, we offer multiple ways to aid seniors maintain their health, well-being, independence and participation in the community, fulfilling our mission. Primary Responsibility
The Medical Social Worker at On Lok PACE at the Institute on Aging (IOA) provides psychosocial assessment and therapeutic counseling to a caseload of clients with complex medical and psychosocial problems. The Medical Social Worker serves as the primary liaison between participants, family members, and the interdisciplinary care team. Specific Responsibilities
The specific responsibilities include: Conducts in-depth biopsychosocial assessments to determine participant needs across multiple domains. Utilizes evidence-informed interventions to solicit participant goals, and develops and initiates a participant-centered care plan. Joins Primary Care Providers and Registered Nurses to form a core primary care team for each participant. Develops a rapport and maintains a care management relationship with participants and members of their support system. Partners with the assigned Care Manager and other interdisciplinary team members to coordinate care for participants with complex needs. Provides supportive counseling to assist participants in coping with illness, grief, and loss. Facilitates family and care team meetings to ensure alignment and promote decision-making around end-of-life planning. Cultivates relationships and partnerships with community providers that support and extend social work interventions. Facilitates the enrollment of On Lok PACE participants at IOA in partnership with the On Lok PACE enrollment team. Fulfills an advocacy role, when necessary, within the interdisciplinary setting and within community programs. Facilitates behavioral health referrals and helps monitor efficacy of behavioral health interventions. Consistent with program guidelines, meets regularly with participants to review progress on plan of care goals. Documents all service delivery and encounters in the participant's electronic health record. Educates participants and their support system about available resources. Establishes and maintains open and effective communication with the interdisciplinary team and other involved community providers. Working closely with other disciplines and health professionals, continuously evaluates and promotes the participants' ability to remain safely in the community. Participates in quality improvement studies and data collection. Attends and actively participates in interdisciplinary team and program meetings. Recognizes clinical or personal limitations by utilizing supervision, when necessary. Understands and applies the regulatory and procedural requirements of the social work discipline within PACE. Remains current in the field of professional social work. Participates in and promotes ongoing efforts towards continuous quality improvement initiatives. Actively incorporates the ethical standards of the National Association of Social Workers. All other reasonably related responsibilities as assigned. Requirements
The requirements include: Must hold an MSW from an accredited school of Social Work. At least one year of professional experience working with frail elderly. At least one year of experience working in an interdisciplinary care model. Licensure is not required but supervision toward LCSW licensure is provided. Background and Experience
The background and experience include: Experience with and understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly. Exceptional communication and presentation skills relating to the frail elderly, functionally impaired adults, their support systems, and teams of health professionals. Detail oriented with good problem-solving skills and the ability to prioritize multiple tasks. Computer literacy preferred. Bilingual Cantonese, Spanish preferred. Compensation
The compensation range is $40.43 - $48.32. This amount is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any specific employee, which is always dependent on actual experience, education, and other factors. This range does not include any additional equity, benefits, or other non-monetary compensation which may be included.