Social Worker - MSW

JOB PURPOSE

The Social Worker provides direct case management services to On Lok participants. The primary role of the MSW is to assist participants and their family/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence. Under the supervision of Regional Social Work Manager with additional oversight from the Center Director and support from the Social Work Lead (SWL) at the center, the MSW serves as an integral member of the Interdisciplinary team (IDT) providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families.

ROLES AND RESPONSIBILITIES

CLINICAL PRACTICES & CASE MANAGEMENT

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Utilize independent judgement and discretion to provide case management to a panel of participants.

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Conduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.

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Partner with caregivers and support system to develop care plan and deliver services.

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Identify risks and other psychosocial problems.

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Identify service needs of each participant; advocate, refer, coordinate and follow up in a timely fashion.

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Provide individual counseling.

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Facilitate family conferences.

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Reach out to the larger community to meet participants’ specific needs.

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Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.

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Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.

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May review and verify the findings of assessments conducted by non-MSW social workers.

INTERDISCIPLINARY TEAM MEMBER

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Act as the main liaison between participants, caregivers, the team, and the community.

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Work with relevant departments such as Health Plan and other community agencies (e.g. RCFE, NF, DAAS)

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Adhere to all ethical and legal standards of social work practices.

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Comply with all On Lok policies & procedures including but not limited to PACE, safety, and confidentiality requirements.

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Fulfill all documentation requirements in a timely and accurate manner.

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Actively participate in team meetings, advocate for the needs of participants and their caregivers, compromise differences among team members, support and carry out team plans.

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Incorporate the Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.

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Assist in the continuous quality improvement of social work services and efficiency of systems.

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All other reasonably related duties as assigned.

REQUIRED QUALIFICATIONS

Master's Degree

Graduate of an accredited college with a MSW degree

Or

Master's Degree

with the required language and experience

Or

Bachelor's Degree

with the required language and experience

Minimum one-year experience with the frail or elderly.

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Experience or ability in working with a diverse population.

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Experience working within the framework of an interdisciplinary team.

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Good interpersonal skills including ability to work cooperatively on an interdisciplinary team.

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Highly organized, able to prioritize tasks and conduct thorough follow-up.

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Excellent written and verbal communication skills.

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Computer literate and basic knowledge of Microsoft Office.

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Bilingual ability may be required for specific assignments.

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Clinical Practices and Case Management.

Clinical\MSW - Medical Social Worker

Valid Social Worker license in California.

PREFERRED QUALIFICATIONS

Minimum one-year post MSW experience.

Minimum one-year case management experience.

Minimum one-year health care related experience.

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Experience with electronic health record system.