Golden Valley Health Centers - Modesto, CA
posted 3 days ago
Modesto, CA
Ambulatory Health Care Services
About the position
Responsible for providing support and advocacy services to patients of the Central Valley PACE program, including participant screening, assessment, planning, coordination of patient services and care, counseling and referral. Schedule is Monday - Friday, working 8:00am - 5:00pm.
Responsibilities
- Participates in the Multidisciplinary Team's initial assessments, care planning and periodic re-assessments (minimally every six (6) months) of participant's case.
- Maintains current written case management records, including periodic reassessments of program participants.
- Coordinates 24 hour care delivery.
- Provides individual and family counseling, develops and leads group counseling and activities.
- Refers participants and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.
- Encourages effective relationships among staff geared to team building and maintenance of a cohesive team.
- Consults with and advises staff members as to the relationship of social, emotional and cultural factors to health and medical care.
- Participates in Program and Policy development of Social Work component.
- Documents participant changes appropriately in the medical record.
- Assumes responsibility for implementation and coordination of the discharge plan.
- Participates as a member of the Interdisciplinary Team.
- Attends staff meetings and takes part in participant care planning.
- Observes each participant for any change in physical, mental, emotional and social functioning and reports such changes to the licensed nurse.
- Assists in providing information and education regarding PACE services.
- Addresses any participants' inquiries, providing guidance and assistance with any coordination and delivery of services.
- Facilitates communication among service providers, family, participants, and caregivers.
- Conducts home visits, hospital visits, nursing skill facilities visits as required.
- Interacts professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
- Completes other projects and duties as assigned.
Requirements
- Must have excellent oral and written communication skills.
- Valid CA Driver's License, acceptable driving record, and vehicle insurance.
- Bilingual (English/Spanish preferred).
- Proficient in Microsoft applications and use of electronic health data systems.
- Demonstrates ability to be culturally sensitive and respect diversity.
- Passion for service; self-starter and highly organized.
- Ability to prioritize, and complete a large volume of work within strict time deadlines.
- Provide prompt, efficient and responsive customer service.
- Individual therapy skills for geriatric participants.
- Analytical thinking and problem solving abilities.
- Meet a standardized set of competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently.
Nice-to-haves
- Master's Degree from an accredited school of Social Work.
- Current BLS CPR Card certified by the American Heart Association.
- Two (2) years health related experience preferred.
- Minimum one (1) year experience working with the frail or elderly population, preferred.
Benefits
- Medical: (0 Deductible / $2,000 Individual; $4,000 Family Out-of-Pocket Max)
- Excellent PPO coverages
- Dental
- Vision
- 403(b) with match
- FSA plans
- Gym discounts
