On Lok PACEWe are a non-profit committed to our participants.Dedicated to The Care of Elders:PACE (Program of All-Inclusive Care for the Elderly) was developed to answer the many problems around caring for frail seniors. The PACE model is 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 community whenever possible.Seniors, their family members, and caregivers face many issues, including transportation to appointments, management of medications, coordination of medical care from different specialists, lack of social interaction, and ability to stay alone at home. On Lok PACE participants receive in home care services and transportation to a On Lok PACE center for primary medical care, social and recreational activities, and other senior care services.We understand the importance of a system that works together. Your expertise, drive and passion can help us carry out our mission to improve lives and advance healthcare.Join our team of leaders to begin a rewarding career!POSITION SUMMARY: The Social Work Lead (SWL) provides direct case management services to On Lok participants and as acts as the subject matter expert (SME) providing department leadership including administration, mentorship, and consultation at an appointed center. The primary role of the SWL is to assist participants and their family/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence. With oversight from the Regional Social Work Manager and the Program Manager, the SWL serves as an integral member of the Interdisciplinary (IDT) team providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families. DUTIES / RESPONSIBILITIES:Clinical Practices and Case ManagementUtilize independent judgement and discretion to provide case management to a panel of participantsConduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.Partner with caregivers and support system to develop care plan and deliver services.Identify risks and other psychosocial problems. Identify service needs of each participant, advocate, refer, coordinate and follow up in a timely fashion. Provide individual counseling. Facilitate family conferences.Reach out to the larger community to meet participants' specific needs. Act as the main liaison between participants, caregivers, the team, and the community. Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.Interdisciplinary Team Member Roles and ResponsibilitiesAct as the main liaison between participants, caregivers, the team, and the community.Work with relevant departments such as Health Plan and other community agencies e.g. RCFE, NF, DAAS (Department of Adult and Aging Services).Adhere to all ethical and legal standards of social work practices.Comply with all On Lok policies & procedures including but not limited to PACE, safety, and confidentiality requirements.Fulfill all documentation requirements in a timely and accurate manner.Actively participate in team meetings, advocate for the needs of participants and their caregivers, compromise differences among team members, support and carry out team plans.Incorporate the Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.All other reasonably related duties as assignedLead ResponsibilitiesIs the subject matter expert (SME) of the electronic health record for the social work department.Assist in the review and update of department and IDT policies and procedures. Assist in the orientation and training for new Social Workers and Social Work Aides.Assist in overseeing competencies for social workers.Assist in developing, maintaining and facilitating relationships with other clinical disciplines and non-clinical staff in order to deliver quality participant care at appointed center.Assist with developing the social work education program.Primary point-person for social work issues at appointed center. Assist in providing support to Social Workers at appointed center.Assist in the continuous quality improvement of social work services and efficiency of systems.Actively participates and contributes to the Social Work Leadership Council (SWLC) activities.Assist with developing the social work continuing education program.Is the primary point-person for social work issues at the appointed center. Contribute additional clinical and/or workflow process perspective regarding participant care to Program Manager in support of the MSW and SWA, as requested.Assist in coordinating student placements (interns) including training, oversight, and evaluations.Actively participate as a change agent in On Lok's organizational vision and mission.All other reasonably related duties as assigned. QUALIFICATIONS (knowledge, skills, abilities):Graduate of an accredited college with a MSW degree.Three years' experience in social work.Minimum two years' experience in the geriatric field and/or with a frail population. At least one year of leadership experience. Experience or ability in working with a diverse population.Experience working within the framework of an interdisciplinary team.Good interpersonal skills including ability to work cooperatively on an interdisciplinary team.Highly organized and has the ability to prioritize and work under extreme pressure. Excellent written and verbal communication skills.Flexible, creative problem solver.Computer literate and basic knowledge of Microsoft Office.Bilingual ability may be required for specific assignments.Experience with electronic health record system (preferred).Minimum two years case management experience in geriatric field (preferred).Minimum two years health care related experience (preferred).Five or more years' experience in social work (preferred). WORKING CONDITIONS:Required to work in the field such as participant's home and other community settings.May be required to travel to other locations for meetings or trainings.Required to work in a fast pace, highly distractible setting.PHYSICAL & MENTAL REQUIREMENTS:While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee occasionally is required to climb and stoop, kneel, crouch, or crawl. Specific vision abilities required by this job include close vision, and ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.The employee must occasionally lift and/or move up to 25 pounds. On Lok's Employee Benefits include (eligible for any regular position for 20 hr/wk or more):Medical, Dental, and Vision coverageRetirement Savings Plan 403(b) and Term Life/AD&D InsuranceFlexible Spending Account, Commuter Benefits, Pet Insurance, and Employee Discount ProgramMental Wellness Resources and Employee Assistance Program (EAP)Holidays (10 per year), vacation time, sick leave, long-term disability insurance, and additional benefits are available.Your final compensation offer will be determined based on factors such as skills, experience, education, and licenses/certifications. The pay range is expressed as an hourly rate regardless of FLSA status. Exempt positions are paid salaried and are not subject to overtime.Pursuant to the San Francisco Fair Chance Ordinance, and state and federal laws (including federal PACE requirements at 42 CFR 460.64(a); 460.68(a), we will consider for employment qualified applicants with arrest and conviction records.On Lok is an equal opportunity employer committed to a diverse and inclusive workforce. All applicants will receive consideration for employment without regard to sex (including pregnancy), race, religion, color, gender, gender identity, gender expression, sexual orientation, national origin, ancestry, disability, medical condition, genetic information, marital status, age, military or veteran status, or any other legally protected status. If you require reasonable accommodation to participate in the job application or interview process, to perform essential job functions and/or to receive other terms, privileges or benefits of employment please contact Talent (recruitment@onlok.org).
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