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Responsibilities

The Social Worker, MSW 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.

This role requires being on-site at the center and field-based work, including visits to participants’ homes and other locations, to ensure continuity of care and support.

Essential Functions and Work Responsibilities

Functional Category: Assessment & Care Planning

• Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status).
• Completes in-person reassessments at least every six months or as required.
• Performs in-home visits as required by regulations or as indicated
• Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care.
• Facilitates and documents participant care conferences, family meetings, and facility partnership meetings.
• Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined.
• Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available.

Functional Category: Case Management & Care Coordination

• Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues.
• Coordinates respite SNF, ALF admissions, including transportation and discharge planning.
• Documents housing encounters in EPIC
• Collaborate with comfort care team for end-of-life activities
• Assists participant’s family with end-of-life coordination
• Collaborates with RN Case Management on hospitalizations, and provides psychosocial input
• May serve as back-up to RNCM.
• Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate.
• Coordinates guardianship process for participants lacking decision-making capacity without a surrogate.
• Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported.
• Provides options counseling when appropriate
• Assists participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork.

Functional Category: Psychosocial Support & Advocacy

• Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated
• Completes comfort care assessments and provides guidance on transitions to end-of-life services.
• Advocates for participants living in unsafe housing conditions
• Contributed to RCAs development, incident reporting, and follow-up for abuse, neglect, exploitation, and elopements.
• Assists participants and caregivers with grievances and appeals, explaining rights and processes.
• Provides notification and explanation of participant rights regarding Level of Care (LOC) denials or disenrollment declines.

Functional Category: Documentation & Compliance

• Maintains accurate and timely documentation in Epic, EireneRx, and other systems (demographic updates, address/phone changes, participant chart updates).
• Complete PASSR screenings, supportive housing forms and other like documents as mandated by federal and state agencies within regulatory timelines.
• Supports Medicaid eligibility recertification processes,
• Partners with Eligibility Financial Determination teams to educate participants/families on required information/documentation needed to maintain and restore Medicaid eligibility
• dictation, and assists with resource compliance.
• Accurate and timely reporting of disenrollments in required systems
• Escalates to Center Director service recovery is needed for a participant concern or disenrollment
• Ensures all participant care coordination complies with CMS, HCPF, and InnovAge policy requirements.

Functional Category: Professional Development & Team Collaboration

• Participates in IDT and department meetings, cross-site collaboratives, trainings, and annual competencies.
• Provides community education and participates in external support groups, inter-agency coordination, and partnership meetings with RCFEs as indicated
• Coordinates with facilities on participant needs.
• Provides caseload coverage support as assigned for MSW PTO, open FTEs, and general team needs.

Performs other duties as assigned

Travel Requirements

Travel

• Travel may be required
• Overnight travel may include local or out of state

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

REQUIRED

Education

• Master’s degree from a school of social work accredited by the Council on Social Work Education

Licensure, Certification, Registration or Designation

• Require personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law.
• CPR/BLS and First Aid a plus

Work Experience and Qualifications

• One year experience in a health care setting
• Experience conducting psychosocial assessments, care planning and case management skills required.
• Requires personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law.
• A minimum of one year experience working with the frail or elderly.

PREFERRED

Work Experience and Qualifications

• Three years or more of social work experience with the elderly