Social Services Specialist (BSW)

RESPONSIBILITIES AND DUTIES:

ESSENTIAL JOB FUNCTIONS:

• Coordinates with the Interdisciplinary Team and to assist the Social Worker in efforts for the development of the participant plan of care.
• Contributed to team discussion of participant issues.
• Acts as liaison with participants and caregivers regarding orientation to and ongoing relations with interdisciplinary team, day center, and other RMHCS staff.
• Provides ongoing support and education to participants and family regarding a variety of issues, including but not limited to the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics, and changing roles.
• Assists participants with housing through intervention with participants, caregivers, and housing management. Will proactively work to partner with participant, MSW Social Worker and/or caregivers to maintain appropriate housing and assist participant to function at most independent community level possible.
• Coordinates with MSW Social Worker with participant admissions/discharges to contracted facilities for temporary respite and permanent placement.

• Keeps a current census of facility availability, maintaining results in the PACE shared drive for review.
• Performs home visits as needed with MSW Social Workers.
• Monitors Social Work Department voice mail/Dept email, following up with partcipants and MSW Social Worker as needed.
• Co-Facilitates meetings with family, caregivers, MDPOA/Guardian, and participant.
• Provides referrals to the HIM Department for contracted facilities and assisted living residences. This may involve completing applications, obtaining medical records, accompanying participants to interview assessments, tours if participant has no other support systems and PASSR completion.
• Assists the MSW Social Worker in facilitation of participant transitioning between all levels of care if no other family or support systems are present.
• Assist in the completion/submission of demographic forms, transportation requests, financial forms (Peti, R&B) as specified by Manager/Supervisor.
• Assist in the coordinate’s hospital discharges in communication with appropriate departments and providers.
• Follows up with communication and further intervention as needed with participant requests.
• Initiates referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocates with these entities for purposes of maintaining community stability.
• Maintains current documentation in participants medical records including narrative, temporary or permanent placements; hospital discharges; participant staffing’s; home visits; and performs chart reviews and audits as needed or requested by the Manager/Supervisor.
• Assists participants with SSI, SSDI, LEAP application process as needed or by request of MSW Social Worker as time allows.
• Assist in reviewing care plans with participants as assigned by the Social Work Manager and/or Social Work Supervisor.
• Attends IDT as requested by the Social Work Manager and/or Social Work Supervisor.
• Assists participants and caregivers in filing grievances, as needed.
• Refers potential voluntary disenrollment due to dissatisfaction with the MSW Social Worker.
• Assists participants and family in coordination with Rocky Mountain PACE Medicaid Department to keep resources within guidelines for Medicaid eligibility.
• Assist in determined meetings by The Social Work Manager and/or Social Work Supervisor, to include scribing meeting minutes.
• Other duties as assigned by the Social Work Manager and/ or Supervisor.

KEY PERFORMANCE INDICATORS

• (List expectations in terms of measurable outcomes. For example, processes 20-25 assessments per day. Conducts 4 home visits per month. Etc.)