Working under the supervision of the PACE Center Manager, the PACE Social Worker Assistant is responsible for supporting PACE Social Workers in the provision of psychosocial services to Participants of the North East Medical Services PACE program. They will be responsible for case-management under the guidance of the Social Worker to help manage long-term care needs.

ESSENTIAL JOB FUNCTIONS:

• Assists Participants with applications and access to community resources and social services such as CalFresh, and housing applications.
• Refers Participants and participants’ families to appropriate community agencies or facilities. Serves as a liaison with the Participant’s family and the team.
• Assists the PACE Social Worker with case-management for hospital discharge, SNF/ALF admission, and discharge.
• Provides telephone support and visits Participants their homes when indicated.
• Escorts Participants to appointments arranged by the Social Worker and/or IDT.
• Assists Participants with document management.
• Serves as a liaison between the PACE Social Worker and the Participant or the Participant’s decision-maker, providing instruction, guidance, or advice.
• Supports the IDT’s Care Planning meetings and processes.
• Coordinates family meetings, and other meetings for participants and the team.
• Adheres to HIPAA principles by maintaining privacy and confidentiality.
• Communicates and coordinates care as needed for participants with the IDT, other facilities, agencies, hospitals, SNFs and ALFs.
• Helps the PACE Social Worker with written case management records and documentation.
• Ensures continuity of care by supporting transitions of care including enrollment, disenrollment, placement, etc.
• Participates in Participant group activities, support groups, outings, etc.
• Utilizes Epic appropriately and efficiently and serve as content and workflow expert for resolving issues and proposing solutions in Epic.
• Performs other job duties as required by manager/supervisor.