Social Work, MSW

Horizon PACE is excited to announce an amazing opportunity to be part of Horizon PACE's program (Program of All-Inclusive Care for the Elderly). This innovative program is for individuals 55 years or older, who are living with chronic illness, or disabilities and need coordinated medical care to continue living as independently as possible in their home and community. The healthcare team at Horizon PACE will approach coordinating medical, social, and home care services so individuals no longer need to manage their medical care alone. Horizon has over 25 years' experience providing care in Kentucky and is the largest provider of adult day health care services in the state. Horizon is opening 3 PACE locations in Kentucky, and we are excited to expand services to older Kentuckians. Horizon has an excellent benefit package including competitive pay, medical, dental, vision, life coverages, as well as generous paid time off, holidays, 401K, and many more.

Under the supervision of the PACE Center Director, the Social Worker (MSW) plans, organizes and implements social work services to Horizon PACE's participants and families. Responsibilities include but are not limited to assessment, treatment, teaching and counseling to participant, caregiver or other appropriate representatives. The Social Worker Interventions could include individual participant contacts; appropriate collateral contact; participant and family education, assessment, and counseling; provision of resources; addressing mental health needs as they arise; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The Social Worker is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.

Position Responsibilities:

· Performs in person initial assessments for enrollment of potential Horizon PACE's participants to obtain a complete psycho-social history, which may include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs.

· Conducts in person reassessments of enrolled participants every six months and as needed.

· Functions as a member of the interdisciplinary team.

· Acts as liaison with participant, caregivers, and community agencies.

· On an annual basis (during annual or semiannual reassessment) presents the written participant rights documentation to assigned participants and or caregiver.

· In the event of termination of Horizon PACE, the social worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination.

· Provides ongoing support, counsel, and education to participants and family regarding a variety of issues.

· Works to maintain participant housing through intervention with participant, caregivers, and housing.

· Presents requests to interdisciplinary team for and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement.

· Acts as facilitator for meetings with participant, family, caregivers, and community agencies.

· Provides referrals to and assessments with subsidized housing and assisted living residences.

· Performs visits within 24 hours of hospital admissions or on Monday if participant is admitted on Friday or weekend. Coordinates hospital discharges in conjunction with interdisciplinary team and communication with attending physician.

· If end of life care is appropriate, actively provides emotional support, grief work, education, and funeral/financial planning referral

· Initiates referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies.

· Assists participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.

· Attends and actively participates in a variety of organizational meetings related to participant care or daily operations.

· Acts as a resource to other team members and day center staff.

· Completes and ensures completion of documentation of clinical service.

· Assists participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.

· Assists participants and caregivers in filing grievances and appeals.

· Assists participants and family to keep resources within guidelines for Medicaid eligibility.

· Acts only within the scope of his or her authority to practice.

· Follows Horizon PACE Policies and Procedures and applicable OSHA safety guidelines.

· Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.

· Practices Universal precautions.

· Maintains safe working environment. Follows Horizon PACE Safety Policies and Procedures.

· Participates in and supports Quality Improvement initiatives

· Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.

Knowledge & Abilities:

· Supports the Mission, Values, and Vision of Horizon PACE and adheres to the Corporate Compliance Code of Conduct.

· Is knowledgeable of participant rights and ensures an atmosphere which allows for the privacy, dignity and well-being of all participants in a safe, secure environment.

· Supports, cooperates with and implements specific procedures and programs

· Supports and participates in common teamwork

· Assist supervisor with various tasks to support department operations as directed; may also be assigned special projects.

· Perform tasks which are supportive in nature to essential functions of the job, but which may be altered or re-designed depending on individual circumstances.

· Assists participants and caregivers in filing grievances.

Experience & Education:

· Master's degree in Social Work from an accredited school of social work or be a Licensed Clinical Social Worker.

· Member of the Academy of Certified Social Workers (ACSW) or other NASW-recognized certification preferred.

· 2 years' experience working on an interdisciplinary team in a hospital, nursing home or community-based setting is preferable.

· Preferred to have 1 year working with the frail or elderly

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Flexible spending