Social Worker

Minimum Qualifications

• Master’s degree in Social Work from an accredited college or university and 2 years of experience in a health‑related field; or an equivalent combination of education and experience.

• 1 year of experience working with the elderly population within the last 3 years.

• CPR and First Aid Certification, or ability to obtain within 6 months of hire.

• Valid driver’s license, reliable transportation, acceptable driving record, and current auto insurance (role requires 30%+ travel).

• Ability to work independently, exercise sound judgment, and communicate clearly in writing and verbally.

• Proficiency with Microsoft Office (Word, Outlook, Excel, PowerPoint) and job‑specific systems.

Preferred Qualifications

• 1 year of case management experience with elderly populations.

• Bilingual in English and one of the threshold languages: Arabic, Farsi, Chinese, Korean, Russian, Spanish, or Vietnamese.

Responsibilities

Care Management — 70%

• Participate in a mission‑driven culture emphasizing high‑quality performance, customer service, dignity, and accountability.

• Participate in IDT assessments (initial, 6‑month, annual) and care planning according to standards.

• Document participant changes in the medical record per departmental and industry guidelines.

• Communicate effectively with IDT members regarding participant needs and status.

• Assess for high‑risk situations (suicidal/homicidal ideation, abuse) and report per legal/ethical standards; engage in safety planning.

• Develop and lead group counseling and participant support activities.

• Refer participants/families to community agencies; serve as liaison and advocate.

• Assist with advance directives, mortuary arrangements, funeral planning, and facility placement.

• Support participants in identifying financial/third‑party resources for services.

• Address psychosocial needs (anxiety, depression, behavioral concerns) in center and home settings.

• Collaborate with IDT to develop discharge plans for PACE disenrollment.

• Conduct home visits as required; frequent travel within Orange County.

• Support care coordination needs (transportation, family communication, scheduling, warm handoffs).

• Advocate for participant care needs, provide supportive counseling, develop psychosocial care plans, and implement interventions.

Support Services — 25%

• Support departmental responsibilities and contribute to short‑ and long‑term goals.

• Advise staff on social, emotional, and cultural factors affecting health and medical care.

• Participate in in‑services, staff meetings, and case conferences.

• Support new enrollee onboarding to the PACE program and ensure service gaps are addressed.

• Participate in Social Work department program improvement.

• Collaborate with Quality Improvement (QI) on grievances, appeals, and participant rights advocacy.

Other — 5%

• Complete additional projects and duties as assigned.

Knowledge & Abilities

• Build rapport and maintain effective working relationships across diverse teams and external partners.

• Work independently in a fast‑paced environment while managing multiple projects.

• Demonstrate strong organization, analytical thinking, problem‑solving, and project management skills.

• Lead and motivate multi‑program teams and external coalitions.

• Identify opportunities for collaboration internally and externally.

• Work a flexible schedule, including evenings and weekends as needed.

• Use computer systems and software to produce correspondence, charts, spreadsheets, and other documentation.

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