About the Role

The Social Worker plans, organizes and implements social work services to participants and their caregivers in accordance with Seen Health policies and all applicable regulations. As an integral member of an Interdisciplinary Team, the social worker performs psychosocial assessments, develops and implements plans of care, conducts counseling and case management, and facilitates communication between the participant, family, caregivers, PACE staff, and provider support network, as appropriate.

Responsibilities 

• Conduct Social Work assessments to determine the psychosocial needs, preferences and goals of the participants and actively participate in IDT meetings to develop participant care plans.

• Deliver and document social work interventions as agreed upon in the participants’ care plans including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual as well as group counseling and case management.

• Completes initial assessments, re-assessments, and care plan updates for participants while continually evaluating the participants' social service needs and caregiver support needs.

• Participates in regularly scheduled behavioral management meetings with other mental health professionals.

• Work with the primary care physician and other members of the care team to guide smooth care transitions between settings (e.g., hospitals, skilled nursing facilities, home, etc.).

• Assists physician, or intermediate care provider, and other team members in understanding the significant social and emotional factors related to participant health problems.

• Acts as a resource to other team members and staff regarding topics such as dementia, difficult behaviors, and difficult personalities. Supports the IDT in establishing behavior management plans.

• Strive for continuous growth and development of cultural competency exhibiting an understanding, awareness, and respect for diversity.

• Maintains accurate and timely documentation and paperwork including participants’ electronic medical records according to policies and procedures.

• Provides referral support to community resources and participates in inter-agency coordination of care.

• Develops and maintains working relationships with community agencies, such as the Department of Social Services, psychiatric facilities, skilled nursing facilities, hospitals, social agencies, and may participate in hospital and/or SNF discharge planning.

• Initiate, coordinate and facilitate care conference meetings to ensure the highest level of care coordination among other care team members, participants, and other people within the participants’ support network (family, informal caregivers etc.).

• Responds to, investigates, and reports complaints of elder abuse.

• Maintains the confidentiality of all company procedures, results and information about participants, clients or families in conformance with Health Insurance Portability and Accountability (HIPAA) principles.

• Active contributor and change agent to continuously achieve quality care, participant experience and compliance goals.

• Proactively supports participant grievance and incident reporting processes.

• Completes timely discharge planning.

• Conducts home visits and travel to hospital facilities and/or other community  agency, as needed.

• Participate in state and federal audit preparation activities.

• Performs related duties as assigned.

Qualifications

• Master’s degree from a school of social work accredited by the Council on Social Work Education.

• Minimum one year experience working with frail and elderly population. (3+ years social work experience preferred).

• Experience conducting psychosocial assessments, care planning and case management skills required.

• Demonstrated ability to work in a multicultural and multidisciplinary team environment.

• Excellent oral and verbal communication and meeting facilitation skills

• Previous experience assisting persons with behavioral health & substance abuse issues, preferred.

• Bilingual ability preferred (Mandarin, Cantonese and Spanish)

• Current CPR certification or the ability to obtain CPR certification is required.

• Require personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law.

Location

• Los Angeles required. 

• On Site at Seen Health in Alhambra; home and community facility visits as needed.

• Relocation benefits available.

Salary & Benefits 

• Salary: $90K - $110K / year
• Equity: may be included as part of team package
• Benefits: Seen Health is proud to offer a robust benefits offering for our employees. In addition to traditional healthcare coverage, we also offer additional benefits to help further your wellness and feeling of being part of the team.
  • Medical, Dental, and Vision benefits for you and your family
  • Life Insurance and Disability Benefits
  • Parental and Caregiver Leave
  • Lunch, as well as delicious snacks and coffee to keep you energized
  • Paid Time Off across holidays, vacation time, personal days, and sick days
  • 401k Plan
  • Personal and professional development, including CME support and career growth opportunities
  • Subscriptions and training on using AI tools including ChatGPT

About the Role

The Social Work Assistant is responsible for assisting and managing a caseload of participants working in close coordination with the Seen Health Interdisciplinary Team  (IDT) and Social Worker. The Social Work Assistant functions as a liaison between the  participants, their family members, and the IDT assist participants by offering advice, implementing treatment plans, coordinating community services, and completing necessary  paperwork. The Social Work Assistant collaborates effectively with colleagues and  stakeholders to promote the Seen Health values, team culture and mission.

Responsibilities 

• Assist Social Workers (MSWs) with daily tasks that may arise. Escalate to MSW or identified appropriate staff member as needed.
• Establish rapport with participants and families to provide psychosocial support.
• Complete IDT care plan reviews with participants and family members within regulatory  time frames.
• Deliver and document social work interventions as agreed upon in the participants’ care plans including but not limited to check in calls, arranging necessary resources and services, and assisting with care transitions, and case management. 
• Participate in IDT adhoc and care conference meetings to provide input, and function as the administrative support to MSW to include transcribing meeting notes and documentation as needed.  
• Remain alert to pertinent input from other team members, participants, and caregivers and update the IDT/Social Worker promptly of any changes in participants’ condition or  psychosocial status.
• Connect participants or families with social and community services. Arrange meetings with relevant agencies, while serving as the advocate for our participants every step of  the process.
• Assist with completing grievances, appeals incident reports, APS reports, and other quality and compliance requirements as needed. 
• Maintain an up-to-date roster of relevant agencies.
• Complete discharge planning with participants and or family members when participants disenroll from the program, present to IDT, and provide appropriate documentation to  medical records timely.
• Provide administrative support to MSW for educational in-services to staff, participants, and caregivers/families regarding psychosocial aspects of aging and related issues
• Participate in end-of-life care coordination and support.
• Conduct home visits, hospital visits, skilled nursing visits, as necessary.
• Demonstrate ability to assist participant or family member with completion of identified  application and community assistant programs. Will include but limited to benefit  renewals, housing, DMV needs, utility bills, and other community support needs.
• Complete all required documentation in a timely and accurate manner. 
• Protect privacy and maintain confidentiality of all company procedures and information about team members, participants, and families. 
• Follow Seen Health policies and procedures and participate in any required Quality Improvement activities, staff training and meetings.

Qualifications

• High School Diploma or Equivalency.
• Associate’s Degree in Social Work, Human Services, Social Science, or relevant field preferred.
• Valid State Driver’s License with a clean DMV record.
• Minimum one year experience working with frail and elderly population. (3+ years social work experience preferred).
• Experience conducting psychosocial assessments, care planning and case management skills preferred.
• Demonstrated ability to work in a multicultural and multidisciplinary team environment.
• Excellent oral and verbal communication and meeting facilitation skills
• Previous experience assisting persons with behavioral health & substance abuse issues, preferred.
• Bilingual ability preferred (Mandarin / Cantonese)
• Current CPR certification or the ability to obtain CPR certification is required.
• Require personal transportation, current state issued driver’s license, good driving record and auto insurance as required by law.

Location

• Los Angeles required. 
• On Site at Seen Health in Alhambra; home and community facility visits as needed.

Salary & Benefits 

1. Salary: hourly rate of $20-$27 / hour depending on experience.
2. Equity: included as part of founding team package.
3. Benefits: Seen Health is proud to offer a robust benefits offering for our employees. In addition to traditional healthcare coverage, we also offer additional benefits to help further your wellness and feeling of being part of the team.
   • Medical, Dental, and Vision benefits for you and your family
   • Life Insurance and Disability Benefits
   • Parental and Caregiver Leave
   • Lunch, as well as delicious snacks and coffee to keep you energized
   • Paid Time Off across holidays, vacation time, personal days, and sick days
   • 401k Plan
   • Personal and professional development, including CME support and career growth opportunities
   • Subscriptions and training on using AI tools including ChatGPT
4.