As an integral member of an Interdisciplinary Team, the social worker performs psychosocial assessments, develops and implements plans of care, conducts counseling and case management, and facilitates communication between the participant, family, caregivers, PACE staff, and provider support network, as appropriate. 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.).