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Social Worker, MSW

Company: Rocky Mountain Health Care Services
Location: Colorado Springs
Posted on: January 14, 2019

Job Description:

POSITION SUMMARY: The MSW, Social Worker is responsible for planning, organizing and implementing social work services to Rocky Mountain PACE participants and families. MISSION: Improving lives, Optimizing wellness, Promoting independence CORE COMPETENCIES:

  • Participant Focus
  • Problem Solving
  • Thoroughness
  • Ethical Conduct
  • Communication Proficiency
  • Personal Effectiveness/Credibility
  • Stress Management/ Composure
    • Responsible for care coordination of hospital and sub-acute admissions and discharges
    • Performs discharge planning coordinating admissions/discharges to contracted facilities for rehab, and permanent placement as needed
    • Works with hospital staff, facility employees, and medical teams to ensure smooth admission and discharge of the participant
    • Works closely with the PACE transition team to ensure that all participant family members and MDPOA/Guardian is informed and active in the discharge process, when appropriate.
    • Builds rapport and relationships with all community partners while providing excellent care coordination of the participant.
    • Maintains best practice and ethical social work according to NASW standards with all professionals and support systems involved in the participants care coordination
    • Acts as liaison with participant and caregivers regarding orientation to and ongoing relations with interdisciplinary team, day center, and other Rocky Mountain PACE staff, including volunteers
    • Provides ongoing support 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
    • 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
    • Performs home visits as needed to assess living environment, support system, and safety of the participant.
    • Provides referrals and assessments with contracted personal care boarding homes and assisted living residences
    • Facilitate participant move between residences or assisted care facilities if no other family or support systems are present
    • Initiates referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies
    • Assists participants and caregivers to complete MDPOA, Proxy, and DNR directives as needed
    • Assists participants and caregivers to set up and maintain personal needs accounts
    • Maintains current documentation in participants electronic medical records including change of status; temporary or permanent placements; hospital discharges; participant staffings; home visits; and other significant events
    • Assists participants with SSI and SSDI application process as needed.
    • Refers potential voluntary disenrollment due to dissatisfaction to the participants primary social worker.
    • Assists participants and family in coordination with Rocky Mountain PACE Medicaid Department to keep resources within guidelines for Medicaid eligibility
    • Provide supervision to student interns in MSW internship collaborations between their respective universities and RM PACE
    • Other duties as assigned ORGANIZATIONAL (CORE RATING FACTORS):
      • Demonstrates support of the Companys Mission, Vision and Core Values
      • Provides Exceptional Customer Service
      • Ensures discretion with confidential information in accordance with HIPAA guidelines
      • Supports a collaborative work environment including courteous, helpful and professional behavior
      • Embraces Organizational Excellence through practicing individual time management, efficiency and effectiveness and participating in continuous improvement efforts
      • Adheres to and supports all Company policies and procedures
      • Supports and practices safe work habits in accordance with policies and procedures
      • Brings ideas, problems and concerns forward and participates in resolution and implementation
      • Participates in and completes regulatory compliance trainings within the prescribed deadlines
      • Attends required meetings
      • Maintains skills and knowledge required including written and verbal communication, best practices for industry standards, and computer competency

        Keywords: Rocky Mountain Health Care Services, Colorado Springs , Social Worker, MSW, Healthcare , Colorado Springs, Colorado

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