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 advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

Scheduled Weekly Hours:

Position Overview

ESSENTIAL FUNCTIONS

• 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 REQUIREMENTS

• Master's degree in social work.
• Two years of social work experience. One year of experience working with the frail or elderly population. First aid required. Current license in social work within the state of PACE Organization preferred.
• AHA BLS
• Drivers License

PHYSICAL DEMANDS AND WORK ENVIRONMENT

• Frequent physical demands include: Sitting , Standing , Walking
• Occasional 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 Hear
• Continuous 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 Hearing
• Anticipated 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)

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. 

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.