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Social Worker (MSW) - Full Time Days - Immanuel Pathways Southwest Iowa

Immanuel Council Bluffs, IA
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Job Description

Overview

Plans, organizes and implements social services to Immanuel Pathways participants and families. Responsibilities include but are not limited to:  assessment, treatment, teaching and counseling to participant, caregiver or other appropriate representatives.  Social work interventions could include individual participant contacts; appropriate collateral contacts; participant and family education; assessment and counseling; provision of resources; 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 (IDT), caregiver representatives, and community agencies. Supports and lives out Immanuel's Mission and CHRIST Promises.

Responsibilities

Requirements of Job:

  • Be legally authorized (currently licensed or if applicable, certified or registered) to practice the job's functions and actions in the respective state in which he/she is employed.
  • Only act within the scope of his/her authority to practice in the respective state in which he/she is employed.
  • Agree to abide by the philosophy, practices, and protocols of the PACE organization.
  • Job specific competencies for the Social Worker will be met prior to assuming participant care.
  • Incumbent may be asked to cover for a counterpart at a different PACE Pathways site (only in the state in which he/she is authorized to practice social work) to assess potential or current participants only.

KEY RESPONSIBILITIES

Key Areas

Key Responsibilities and Duties of the Job

55% Participant Assistance within the Center

  • Performs initial in-person assessments for enrollment of potential Immanuel Pathways participants to obtain a complete psychosocial history, which may include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other issues and needs.  Conducts in-person reassessment of enrolled participants every six (6) months and as needed.    
  • Functions as a member of the Interdisciplinary Team.  Coordinates with the team to develop an initial comprehensive plan of care for each participant.  Maintains regular attendance at, and participates in team meetings; communicates participant changes, collaborates on plan of care decisions and coordination for twenty-four (24) hour care delivery. Presents requests to Interdisciplinary Team for and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement. 
  • Presents the written participant rights documentation to assigned participants and or caregiver on an annual basis.  In the event the participant is unable to understand the information, ensures the caregiver or representative understands the participant rights.  If there is a language barrier the Social Worker will provide the appropriate interpreter.
  • Provides 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.
  • May be required to perform home visits based upon an individuals Plan of Care in regards to state applicable Home Health standards and Regulations.
  • Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem solves issues regarding the plan of care.  Mediates discussions between all parties. 
  • Acts as liaison with participant and caregivers regarding orientation to, and ongoing relations with Interdisciplinary Team, Participant Center staff, and other Immanuel Pathways staff, including volunteers.
  • Attends and actively participates in a variety of organizational meetings related to participant care, including but not limited to:  Morning Meeting, Intake and Assessment Meeting, various in-services and community agency meetings.
  • Assists participants and caregivers in filing grievances.
  • Assists participants and family in coordination with Enrollment Coordinator to keep resources within guidelines for Medicaid eligibility.
  • Completes and ensures completion of documentation of clinical service, in participant's medical records including initial assessments, reassessments, change of status, temporary or permanent placements; hospital admissions and discharges, home and nursing home visits and other significant events according to Immanuel Pathways documentation requirements.
  • Works to maintain participant housing through intervention with participant, caregivers and housing.  Will proactively work to partner with participant and/or caregivers to maintain appropriate housing and assist participant to function at most independent community level possible. 

30% Participant Assistance with Outside Agencies

  • Provides referrals to and assessment with contracted Room and Board and Assisted Living residences.  This may involve completing applications, obtaining medical records, accompanying participants to interview assessments and tours if participant has no other support systems. 
  • Performs visits within twenty-four (24) hours of hospital admissions or on Monday if participant is admitted on a Friday or weekend.  Coordinates hospital discharges in conjunction with Interdisciplinary Team and attending physician.  Communicates with family or caregivers frequently and as needed for updates.
  • Facilitates hospice or nursing home placement as needed or requested. Initiate 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.
  • Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.
  • Assists participants with Social Security Income (SSI) Social Security Disability Income (SSDI) application process as needed.
  • Assists participants and caregivers to set up and maintain Personal Needs Accounts. 
  • In the event of termination of the PACE organization, the Social Worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination.  Assists participants in obtaining reinstatement of conventional Medicare, and Medicaid benefits, transition participants care to other providers, make all appropriate referrals make the participants medical records available to new providers with appropriate participant approvals.

10% Compliance

  • Acts within the scope of his or her authority to practice
  • Implements Exposure Control Plan
  • Complies with Emergency Preparedness Plan
  • Uses proper lifting and push/pull techniques, use gate belt assistance and participant transfers
  • Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families. 
  • Participates in and supports Quality Improvement Initiatives.
  • Completes internal or external ISIS PACE Reviewer training.
  • Completes Security Review process for system access in the respective state in which he/she is employed.
  • Maintains up to date knowledge of system\process and communicates to IDT as applicable.
  • Complies with NE Home Health Licensure regulations for home care.

5% Other

  • Acts as a resource to other team members and participant center staff regarding topics such as dementia, difficult behaviors, and difficult personalities. 
  • Participates in continuing education classes and any required staff and training meetings.
  • Maintains professional affiliations and any required certifications. 
  • Performs other duties as required or requested.

Qualifications

Education-

  • Masters Degree from an accredited school of social work required.

Experience-

  • Two (2) years of experience working on a multidisciplinary team in a hospital, nursing home or community-based setting is preferred.
  • One (1) year of experience working with the frail or elderly population required, or completion of job specific training related to working with the elderly population must be completed within the first six months of hire.
  • One (1) year of leadership or management experience, preferably in a geriatric care setting required.

Other Requirements-

  • Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
  • Must have a valid driver's license, proof of insurance and have means of transportation.
  • Basic Life Support (BLS) Skills i.e. Health Care Level Cardiopulmonary resuscitation (CPR); Automated External Defibrillator (AED); First Aide (FA).

KSA- Knowledge Skills and Abilities-

  • Knowledge of psychology in analysis, intervention and counseling with individuals or in small group conferences.
  • Skilled in counseling techniques, mentoring and coaching, and/or training methods
  • Skilled verbal and written communication, including speaking to groups of people.
  • Ability to work with frail/chronically ill elderly people.
  • Ability to provide psychosocial assessment and individual, family and group counseling.
  • Ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.
  • Ability to communicate clearly and effectively.
  • Ability to chart via Electronic Health Records
  • Proven experience and basic computer proficiency (internet, email, Microsoft Office)

Job Details

Date Posted June 18, 2020
Date Closes July 18, 2020
Requisition 2020-3762
Located In Council bluffs, IA
SOC Category 00-0000.00
Location