Social Worker, MSW
Company: InnovAge
Location: Aurora
Posted on: April 28, 2024
Job Description:
Responsibilities
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
team.
Assessment and Care Planning
- Performs initial assessments of 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 program participants, as
well as in other interdisciplinary team settings that plan,
coordinate and monitor the care of InnovAge 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
housing risk.
- 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. Case Management
- Develops a collaborative relationships 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 (applicable for non-Pennsylvania locations). Collaborates with
participants, caregivers, facilities and the IDT to ensure clear
communication regarding participant status and plan.
- 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 for non-Pennsylvania locations, may be
responsible for notifying 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 (applicable for
non-Pennsylvania locations).
- 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 to dissatisfaction.
- 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
Competencies.
- Provides on-call support after hours as assigned, if
applicable. Psychosocial Support
- 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
standards.
- Evaluates quality of psychosocial services provided and adjusts
interventions as clinically indicated.
- Schedules home visits as necessary according to patient
needs.
- 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
plans.
- Strive for continuous growth and development of Cultural
Competency exhibiting an understanding, awareness, and respect for
diversity.
- Provides caseload coverage support as assigned for MSW PTO,
open FTEs, and general team needs.
- Performs other duties as assigned. REQUIRED
- Master's degree from a school of social work accredited by the
Council on Social Work Education
- Current CPR certification or the ability to obtain CPR
certification is required.
- One year experience in a health care setting working with the
frail and elderly
- 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 law.
PREFERRED
- 3+ years social work experience
Benefits
The mission of InnovAge is to allow seniors to live life on their
terms - by aging in place, in their own homes and communities, for
as long as safely possible. InnovAge's Program of All-inclusive
Care for the Elderly (PACE) is an alternative to nursing
facilities. Our enrolled participants receive customized healthcare
and social support at a nearby PACE center supported by a team of
medical experts dedicated to providing personalized healthcare and
support to help them age at home. Our greatest assets are our team
members who make a difference in the lives of those we serve every
day. Elevate your future with co-workers passionate about a
patient-centered care model supported by comprehensive services to
improve the quality of care while reducing over-utilization of
high-cost care settings.
As an equal opportunity/affirmative action employer InnovAge is
committed to and values an inclusive and diverse workplace. All
qualified applicants will receive consideration for employment
without regards to race, color, religion, sex, sexual orientation,
gender, gender identity/expression, national origin, disability or
protected veteran status, pregnancy or any other status prohibited
by applicable law.
Salary ranges are dependent on a variety of factors, including
qualifications, experience, and geographic location and does not
include potential bonus or benefits. Comprehensive benefits include
m/d/v, short and long-term disability, life insurance and AD&D,
supplemental life insurance, flexible spending accounts, 401(k)
savings, paid time off, and company paid holidays.
Posted Salary Range
USD $62,400.00 - USD $68,640.00 /Yr.
Keywords: InnovAge, Arvada , Social Worker, MSW, Healthcare , Aurora, Colorado
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