At WelbeHealth, our vision is a world where every human being participates in our culture through their final days. To make this vision a reality, we provide integrated medical and social services to our most vulnerable seniors, helping to unlock their full potential. We are looking for team members who are energized by working in diverse teams toward our shared purpose, who are eager to drive groundbreaking innovation, and who will interact with those we serve and those who serve them in a spirit of understanding and compassion.
We are launching a PACE (Program of All-Inclusive Care for the Elderly) program in Fresno, CA. The PACE program serves as our patients’ health insurer and directly provides comprehensive primary care and social services to keep them living safely in the community. Reporting to the Clinical Services Director, the Social Worker will manage a caseload of participants working in close coordination with the Sequoia PACE Interdisciplinary Team (IDT).
You’ll be responsible for:
- Conducting Social Work assessments to determine the psychosocial needs, preferences and goals of participants and actively participate in IDT meetings to develop participant care plans.
- Delivering and documenting social work interventions including arranging necessary resources and services, assisting with care transitions, providing individual and group counseling and case management.
- Working with the PACE Physician and other members of the IDT to support smooth care transitions between settings (e.g. hospitals, skilled nursing facilities, home, etc.).
- Remaining alert to pertinent input from other team members, participants, and caregivers and update the IDT promptly of any changes in participants’ condition or psychosocial status.
- In coordination with the Intake team, facilitating enrollment of prospective participants into the program.
- Initiating, coordinating and facilitating care conference meetings to ensure the highest level of care coordination among IDT members. participants and other people within the participants’ support network (family, informal caregivers etc.).
- Providing discharge planning when participants disenroll from the program.
- Providing educational in-services to staff, participants and caregivers/families regarding psychosocial aspects of aging and related issues.
- Participating in end-of-life care coordination and support.
- Conducting home visits as necessary.
- Providing support with Medi-Cal and Medicare enrollments to benefits eligibility staff.
Why you’ll love working at WelbeHealth:
- You’re a part of changing healthcare for seniors in Stockton and Modesto and have the opportunity to care holistically for participants.
- You’ll get to work with a team to care for people. This means you have other professionals there to support you in helping change behavior or have difficult conversations with a participant or family.
- You’ll work on a manageable caseload and have the opportunity to get hours toward your LCSW.
- Master’s in Social Work (MSW) required
- Bilingual strongly preferred (Spanish, Cantonese, Mandarin)
- At least one year of experience with a frail or elderly population
- Experience supporting individuals with behavioral health and/or substance abuse issues
- Highly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situations.
- Ability to process accurate information in a timely manner.
- Ability to work independently with minimal supervision.
- Familiarity with local community agencies and resources preferred.
- Bilingual Spanish-English preferred.
- Deep commitment to helping unlock the potential of our most vulnerable seniors.
We believe that unlocking the full potential of our most vulnerable seniors requires a diverse team with a variety of perspectives. We are an equal opportunity employer and individuals seeking employment at WelbeHealth are considered without regard for race, color, religion, sex, gender identity, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), sexual orientation, pregnancy or any other consideration made unlawful by federal, state or local laws.