Work Shift:

Day (United States of America)

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview:

Executes assignments in a culture that is shared and collaborative across all divisions within Capital Health. Promotes and maintains collaborative relationships with managers, peers, direct reports, and customers by effectively fostering a team environment, building consensus, and resolving conflicts.Maintains department budget, places orders for equipment and supplies as necessary. Identifies financial vulnerabilities and makes cost reduction recommendations as needed. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.Knows proper disaster recovery protocol, crisis management, and business continuity plans, and acts within role that is developed within the business continuity plan. Works at another location, remotely from home, and maintains constant contact with key personnel as required.Attends and participates in scheduled training, in-service training, mandatory annual in-service training, and educational classes as required and needed. Participates as a member of the interdisciplinary team (IDT). Communicates participant changes, and collaborates on care planning decisions and coordination for 24-hour care delivery.Performs initial, semi-annual, unscheduled, and annual assessments of participants. Coordinates with IDT to develop comprehensive plan of care for each participant. Participates in the development and implementation of QAPI activities.Conducts initial intake meeting with family members and others, while coordinating ongoing family meetings as needed. Provides individual and family counseling as needed or prescribed in the plan of care and develops and leads group counseling and support activities.Provides ongoing support, counsel, and education to participants and family regarding a variety of issues, including the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model, and PACE health services.Maintains current, written case management records, including ongoing documentation of services provided, reassessment of changing needs and participant's expressed wishes. Performs home visits periodically or as needed to asses living environment and support system.Assists with ongoing financial eligibility for participants, including recertification as needed.Provide training, supervision, oversight and evaluation to case managers and case management to participants and families. Acts as liaison between the participant and other agencies such as Department of Aging, Social Security Administration, and Medicaid.Acts as a resource to other team members, and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.Assists participants and caregivers in filing grievances and appeals. Assures that any personal care needs are communicated to the family with special attention to clothing and DME needs while participants are in hospital or short-term rehab stays and communicate relevant information to the interdisciplinary team about participants while they are admitted.Coordinates discharge planning for participants returning home from hospital or nursing facility.Provides crisis intervention and advocacy as required. Actively provides emotional support, grief work, education, funeral and financial planning referrals when hospice care is appropriate. Facilitates hospice or nursing home placement as needed. Initiates referrals to external resources with community agencies such as Adult Protective.Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.Coordinates transitional care to ensure continuation of care by assisting participants with reinstatement of conventional Medicare and Medicaid benefits, transitions care to other providers, makes referrals, and ensures participant medical records are available to new providers in the event of participant termination of the PACE Program.Performs other duties as assigned.MINIMUM REQUIREMENTSEducation: Master's degree in social work.Experience: Two years of social work experience. One year of experience working with the frail or elderly population. Current license in social work within the state of PACE Organization preferred.Other Credentials: Drivers LicenseKnowledge and Skills: Must possess a comprehensive knowledge of social work. Ability to research, analyze, and assimilate information from various on-site or virtual sources based on technical and experience based knowledge. Must exhibit critical thinking skills and possess the ability to prioritize workload. Experience working on a multidisciplinary team in a hospital, nursing home or community based setting is preferred. Experience and thorough knowledge of social service principles and practices. Knowledge of financing mechanisms such as Medicare, Medicaid, and other payment systems. Demonstrates superior written and verbal communication and presentation skills appropriate for audience comprehension. Well-developed communication skills, both written and oral, that may be used either in an on-site or virtual environment is required. Able to communicate effectively with individuals and groups representing diverse perspectives. Excellent organizational skills. Ability to perform multiple duties and functions related to daily operations and maintain excellent customer service skills. Ability to perform frequent detailed tasks and provide immediate service with frequent interruptions. Ability to change and be flexible with work priorities. Strong problem solving skills.Special Training:Comprehensive to expert proficiency with Microsoft product suite (MS Word, Excel, Power Point, etc.); basic knowledge and experience with electronic mail and calendaring system. Knowledge of social service delivery systems necessary, experience preferred. Ability to type with speed and accuracy. Ability to use other software as required to perform the essential functions of the job.Mental, Behavioral and Emotional Abilities: Possesses a high degree of personal accountability, responsibility and independent decision making abilities with the skills to plan, organize, develop, implement and interpret programs, goals, objectives, policies and procedures of the organization in line with mission, vision, and philosophy of Capital Health PACE. Possesses interpersonal skills to drive collaboration, commitment and productivity when working with cross- functional teams, customers and end users. Must be comfortable functioning in a virtual, collaborative shared leadership environment. Must be action-oriented, have business acumen, manage conflict well, be customer focused, have high decision quality, flexibility to adapt to ongoing change and have organizational agility. Ability to work with minimal supervision and exercise independent judgment.PHYSICAL DEMANDS AND WORK ENVIRONMENTFrequent physical demands include: Sitting , Standing , WalkingOccasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl , Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion , Taste or Smell , Talk or HearContinuous physical demands include:Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 10 lbs.Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate HearingAnticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Chemical , Airborne Communicable Disease , Extreme Temperatures , Radiation , Uneven Surfaces or Elevations , Extreme Noise Levels , Dust/Particulate Matter , Other (List)

Offers are contingent upon successful completion of our onboarding process and pre-employment physical.  Capital Health will require all applicants (including contractors, travelers and consultants) to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

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