Job Description

Essential Job Duties:

Conduct Social Work assessments to determine the psychosocial needs, preferences and goals of the participants and actively participate in IDT meetings to develop participant care plans
Deliver and document social work interventions as agreed upon in the participants’ care plans including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual as well as group counseling and case management
Work with the primary care physician and other members of the care team to guide smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home, etc.)
Initiate, coordinate and facilitate care conference meetings to ensure the highest level of care coordination among other care team members, participants, and other people within the participants’ support network (family, informal caregivers etc.)
Provide discharge planning when participants disenroll from the program
Job Requirements:

Master’s Degree in Social Work (MSW) required
Minimum of one (1) year of experience with a frail or elderly population
Previous experience coordinating and facilitating care conference meetings
Previous experience assisting people with behavioral health & substance abuse issues, preferred

Skills and Certifications
MSW
1 year of experience

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