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:

Evaluates, develops, mentors, coaches, counsels and disciplines department staff. Supports other personnel from other departments through coaching and mentoring to help achieve optimum standard of excellence. Addresses issues of concern through courageous conversation and notifies department manager of any interactions requiring attention.Provides leadership in recruitment, staff selection, orienting, training and developing staff.Implements and enforces systems, policy and procedure and evaluates outcomes to monitor and enforce quality and customer service standards.Performs initial, semi-annual, unscheduled, and annual assessments of participants. Coordinates with IDT to develop comprehensive plan of care for each participant.Assists with 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; develop and lead group counseling and support activities.Provides ongoing support, counsel, 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, 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.Provides training, supervision, oversight and evaluation to social work staff while working with participants and familiesAssures 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.Actively provides emotional support, grief work, education, funeral and/or financial planning referrals when hospice care is appropriate. Facilitate hospice or nursing home placement as needed. Initiate referrals to external resources with community agencies such as Adult Protective.Coordinates transitional care to ensure continuation of care by assisting participants with reinstatement of conventional Medicare and Medicaid benefits, transition care to other providers, make referrals and ensure participant medical records are available to new providers in the event of participant termination of the PACE Program.Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.In conjunction with the interdisciplinary team, coordinate discharge planning for participants returning home from hospital or nursing facility.Performs other duties as assigned.MINIMUM REQUIREMENTSEducation: Master's degree in social work.Experience: Five years related social work experience.Other Credentials: Drivers License,Social Worker - LicensedKnowledge and Skills: Must possess a comprehensive knowledge of psychosocial and behavioral needs. Possess 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. 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.PHYSICAL DEMANDS AND WORK ENVIRONMENTFrequent physical demands include:Occasional physical demands include:Continuous physical demands include:Lifting Floor to Waist 0 lbs. Lifting Waist Level and Above 0 lbs.Sensory Requirements include:Anticipated Occupational Exposure Risks Include the following: N/A

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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