Social Worker
Trinity Health PACE

Job Info

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Employment Type:
Full time
Shift:

Description:

Trinity Health PACE programs are nationally recognized for providing high quality, comprehensive care in the communities we serve. Our services are built upon a 30-year history of Programs of All-Inclusive Care (PACE) for the elderly in the United States. Trinity Health PACE is one of the largest PACE providers in the country with 14 owned and managed programs. We have 19 PACE centers in nine states and we provide care for over 3,000 seniors.

PACE (Program of All-inclusive Care for the Elderly) programs are centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in their own community whenever possible. PACE is a managed-care program that uses an interdisciplinary team approach to provide patients with medical, social, nutritional and rehabilitative services. The PACE program makes it possible for patients to live with dignity and pride in their own homes while receiving the care they need, creating peace of mind for patients and their families. Make a powerful impact on the lives of those we proudly serve and you will feel the importance of your work from the very first day.

POSITION PURPOSE

The primary purpose of your job position is to plan, organize, and implement social services to PACE Organization (PO) participants and families. Responsible for but not limited to assessment, treatment, teaching and counseling participants, caregiver or other appropriate representatives. Social Worker interventions may include individual participant contacts, appropriate collateral contact, participant and family education, assessment and counseling, provision of resources, addressing mental health needed, ongoing case management, advocacy to ensure participant and caregiver needs are met and addressed and disenrollment procedures.
Disclaimer: The following statements are intended to describe the general nature and level of work assigned to this position. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the individual in this position. Other duties may be assigned as deemed necessary or appropriate by management.

ESSENTIAL FUNCTIONS

1. Know, understand, incorporate, and demonstrate the Mission, Vision, Values and Guiding Behaviors of Trinity Health and Trinity Health PACE (TH PACE) in behaviors, practices, and decisions.

2. Consistently demonstrate (leads by example) TH PACE Values to all internal and external customers (participants, visitors, volunteers, and colleagues.) Create and maintain an atmosphere of warmth, propagating a calm environment throughout the office.

3. Execute assignments in a culture that is shared and collaborative across all divisions within TH PACE.

4. Reflects the skills knowledge and abilities serving in the role of a leader. Define and share a strategy and vision; align resources toward achievement of organization results; grow and sustain the organization; identify, lead, and embrace change.

5. Establish and/or maintain as a member of the leadership team a plan to achieve operating goals.

6. Promote and maintain collaborative relationships with managers, peers, direct reports and customers by effectively fostering a team environment, building consensus and resolving conflicts.

7. Maintain department budget, place orders for equipment and supplies as necessary. Identify financial vulnerabilities and make cost reduction recommendations as needed.

8. Evaluate, develop, mentor, coach, counsel and discipline department staff. Supports other personnel from other departments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues of concern through courageous conversation and notifies department manager of any interactions requiring attention.

9. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, TH PACE Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

10. In light of a disaster will know your disaster recovery, crisis management and business continuity plans and act within your role that is developed within the business continuity plan. Which may include working at another location, remotely from home, and maintaining constant contact with key personnel.

11. Attend and participate in scheduled training, in-service training, mandatory annual in-service training and educational classes as required/needed.

12. Participate as a member of the interdisciplinary team (IDT). Communicate participant changes, and collaborates on care planning decisions and coordination for 24-hour care delivery.

13. Perform initial, semi-annual, unscheduled, and annual assessments of participants. Coordinates with IDT to develop comprehensive plan of care for each participant.

14. Involved in the development and implementation of QAPI activities.

15. Conduct initial intake meeting with family members and others, while coordinating ongoing family meetings as needed.

16. Provide individual and family counseling as needed or prescribed in the plan of care; develop and lead group counseling and support activities.

17. Provide ongoing support, counsel, 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, PACE model and PACE health services.

18. Maintain current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and participant's expressed wishes.

19. Perform home visits periodically or as needed to asses living environment and support system.

20. Assist with ongoing financial eligibility for participants, including recertification as needed.

21. Provide training, supervision, oversight and evaluation to Case Managers and case management to participants and families.

22. Act as liaison between the participant and other agencies such as Department of Aging, Social Security Administration, Medicaid, etc.

23. Assist participants and caregivers in filing grievances and appeals.

24. Act as a resource to other team members, and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.

25. Assure that any personal care needs are communicated to the family with special attention to clothing and DME needs while participants are in hospital or short-term rehab stays and communicate relevant information to the interdisciplinary team about participants while they are admitted.

26. In conjunction with the interdisciplinary team, coordinate discharge planning for participants returning home from hospital or nursing facility.

27. Provides crisis intervention and advocacy as required.

28. Actively provide emotional support, grief work, education, funeral and/or financial planning referrals when hospice care is appropriate. Facilitate hospice or nursing home placement as needed. Initiate referrals to external resources with community agencies such as Adult Protective.

29. Assist participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.

30. Coordinate transitional care to ensure continuation of care by assisting participants with reinstatement of conventional Medicare and Medicaid benefits, transition care to other providers, make referrals and ensure participant medical records are available to new providers in the event of participant termination of the PACE Program.

MINIMUM QUALIFICATIONS

1. Must possess a comprehensive knowledge of social work as normally obtained through a Master's degree in social work and two (2) years of experience, including one (1) year working with the frail or elderly population. Current license in social work within the state of PACE Organization preferred. A combination of education and experience may be acceptable.

2. Experience working on a multidisciplinary team in a hospital, nursing home or community based setting is preferred.

3. Experience and thorough knowledge of social service principles and practices.

4. Knowledge of financing mechanisms such as Medicare, Medicaid and other payment systems.

5. Valid driver's license and ability to provide a reliable means of transportation required.

6. State of North Carolina - Must have Employee Medical Statement that meets the requirements of the Standards completed prior to beginning employment, signed within previous 12 months by an MD, NP or PA, indicating that the employee has no illness or health condition that would pose a risk to others and can perform the duties assigned in the job.

7. Must be action-oriented, have business acumen, manage conflict well, be customer focused, have high decision quality, flexibility to adapt to ongoing change and have organizational agility. Ability to work with minimal supervision and exercise independent judgment.

8. Possess interpersonal skills to drive collaboration, commitment and productivity when working with cross-functional teams, customers and end users. Must be comfortable functioning in a virtual, collaborative shared leadership environment.

9. Demonstrates superior written and verbal communication and presentation skills appropriate for audience comprehension. Well-developed communication skills, both written and oral, that may be used either in an on-site or virtual environment is required. Able to communicate effectively with individuals and groups representing diverse perspectives.

10. Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic knowledge and experience with electronic mail and calendaring system. Knowledge of social service delivery systems necessary, experience preferred. Ability to type with speed and accuracy. Ability to use other software as required to perform the essential functions of the job.

11. Possesses a high degree of personal accountability, responsibility and independent decision making abilities with the skills to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures of the organization in line with mission, vision, and philosophy of TH PACE.

12. Excellent organizational skills. Ability to perform multiple duties and functions related to daily operations and maintain excellent customer service skills. Ability to perform frequent detailed tasks and provide immediate service with frequent interruptions. Ability to change and be flexible with work priorities. Strong problem solving skills.

13. Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical and experience based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize workload.

14. Position may require up to 10% travel within the Centers geographic region.

PHYSICAL AND MENTAL REQUIRMENTS AND WORKING CONDITIONS

1. Must be able to adapt to frequently changing work parameters and adapt to work priorities that frequently change. Must be able to work on a variety of tasks/projects in physical or virtual environments that may be stressful with individuals having diverse personalities and work styles.

2. Must be able to see and hear or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.

3. Primarily works inside with frequent kneeling, crouching, reaching, lifting, sitting, walking, bending and lifting. Must be able to push, pull, move and or lift a minimum of 20 pounds if applicable.

• Physical mobility that includes movement from place to place.
• Must be able to sit for long periods of time.
• Physical agility, that includes ability to maneuver body while in place.
• Dexterity of hands and fingers.
• Coordination, including eye-hand, hand-foot.

Must possess the above ability with or without the use of prosthetics that will enable adequate functionality so that the requirements of this position can be fully met.

4. Subject to exposure to noise, infectious waste, diseases, conditions, etc. including TB, HIV, HEP B viruses. May be subject to the handling of and exposure to hazardous chemicals.

5. Must be able to speak, read and write the English language in an understandable manner.

6. Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times hostile customers.

Must possess the ability to deal tactfully with personnel, participants, family members, visitors, government agencies/personnel and the general public.
7. Must not pose a direct threat to the health or safety of other individuals in the work place.

8. Must be able to cope with the mental and emotional stress of the position. Must be able to comply with organizational policies and procedures.

9. Must be able to spend majority of work time utilizing a computer, monitor, and keyboard. Must be able to work with frequent interruptions and perform detailed tasks.

10. Must meet the general health requirements set forth by the policies of this organization, which include a medical and physical examination.

11. May be required to work beyond normal working hours, on weekends and other positions temporarily when necessary and may be subject to call back during emergency conditions. May be required to work on shifts other than those which originally hired.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

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