Geriatric Resources for Assessment and Care of Elders (GRACE) Social Worker

$78,000 - $83,000/Yr

Aloha Care - Honolulu, HI

Full-time - Mid Level

Honolulu, HI

Ambulatory Health Care Services

About the position

The Geriatric Resources for Assessment and Care of Elders (GRACE) Social Worker at AlohaCare is responsible for coordinating geriatric care for adults aged 50 and older with geriatric conditions. This role involves conducting assessments, developing health action plans, and collaborating with an interdisciplinary team to ensure comprehensive care management. The GRACE Social Worker engages with members, families, and healthcare providers to promote optimal health outcomes and quality of life for vulnerable older adults.

Responsibilities

• Conduct face-to-face or virtual Health and Functional Assessments for members enrolled in the GRACE program.
• Engage members and providers to collaboratively develop person-centered Health Action Plans.
• Interact with members, families, and healthcare providers to assess current status and service delivery options.
• Solicit input from a multi-disciplinary team to activate GRACE protocols for care related to geriatric conditions.
• Meet with members at least every 90 days to monitor progress in the Health Action Plan.
• Provide supportive counseling to members and caregivers regarding illness and coping strategies.
• Screen for social risk factors and offer interventions to mitigate their impact.
• Assist members in connecting to social services for housing and medical care needs.
• Document all interactions with members and their families in the electronic record.
• Ensure Health Action Plans are developed within 30 days of assessment completion.
• Facilitate authorization and access to services, monitoring service delivery and member satisfaction.
• Provide education on preventative health care measures and alternatives to nursing facility placement.
• Coordinate care for members transitioning between different care settings.
• Attend interdisciplinary team meetings to review and modify individualized care plans.

Requirements

• Bilingual in Mandarin or Japanese preferred.
• Licensed LSW, LCSW, LMHC, or LMFT in the State of Hawaii.
• Experience with serving members with geriatric conditions in the community.
• Health plan experience with care coordination responsibilities.
• Experience with Medicare/Medicaid programs.
• Experience with individuals having special health care needs.
• Prior nursing home diversion or long-term care case management experience.
• Intermediate computer skills and experience with Microsoft Office products.
• Strong written and verbal communication skills.

Nice-to-haves

• Bilingual in Ilocano, Tagalog, or Korean.
• Ability to communicate using American Sign Language.

Benefits

• Health insurance
• Dental insurance
• Paid time off
• Vision insurance
• 401(k) matching
• Referral program