Job Posting for Social Worker (MSW) at Edenbridge Health
JOB SUMMARY
The Social Worker position offers a unique opportunity to help build the first PACE (Program of All-Inclusive Care for the Elderly) program in the District of Columbia within the framework of a supportive, innovative, and expert leadership team and company.
As a Social Worker at Edenbridge PACE at Skyland Town Center, you will play a critical role in providing essential support to participants and their families. The Social Worker is responsible for assessing psychosocial needs, developing care plans, coordinating services, and advocating for participants in the Program of All-Inclusive Care for the Elderly (PACE).
ESSENTIAL DUTIES AND RESPONSIBILITIES
Responsible for initial, 6 month, change of condition, and annual assessments
Presents assessments at care plan conferences with the goal of providing a foundation for the care plan and team discussion of participant issues
Provides ongoing support and education to participants and families/caregivers covering a variety of issues, including but not limited to the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics, housing, behavioral health concerns, substance dependency issues, and fraud and abuse (experience with APS and DBH a strong plus)
Provide brief, solution focused therapy and group psychoeducation/treatment related to chronic medical conditions
Provide crisis intervention and triage with appropriate interventions
Coordinates admissions/discharges to contracted facilities for temporary respite and permanent placement
Initiates nursing home co-pay status upon discharge from team and supervisor when skilled facility placements become permanent
Performs home visits to participants in ward 7 & 8 as needed to assess living environment and support system
Provides referrals and assessments with contracted assisted living residences
Facilitates participant moves between residences or assisted care facilities
Coordinates hospital discharges in communication with attending medical team members
Initiates referrals to external resources with community agencies
Advocates for participants to ensure their voices are heard in the development and implementation of care plans.
Works closely with community resources and agencies to enhance participant support.
Maintains current documentation in participant medical records including initial assessments (narrative, problem lists, assessment forms); reassessments (updated problem lists and chart note); change of status; temporary or permanent placements; hospital discharges; home visits; and other significant events
Engages in community outreach to enhance awareness of the PACE program and its social services
Other duties as assigned
QUALIFICATIONS
Master’s Degree in Social Work
Current state licensure as a Masters Social Worker (MSW) in Washington, DC
A minimum of one year of experience working with frail or elderly population is required
Experience working on a multidisciplinary team preferable
Must be vaccinated against Covid-19 and free of communicable diseases
Must have a current driver’s license and driving record must be in compliance with Company policy
Experience documenting in an Electronic Health Record preferred
Ability to collaborate effectively within an interdisciplinary team.
Learn more at:
edenbridgehealth.org
Salary.com Estimation for Social Worker (MSW) in Washington, DC
$69,405 to $85,388
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