Social Worker in Depew, NY

Salary Range: $60,000.00 - $65,000.00 per year

EDUCATION: Bachelor’s Degree in Social Work, Psychology, Mental Health Counseling, and/or related field.
EXPERIENCE: Minimum of 3 years experience providing social services to the frail elderly and/or nursing home population.
EXPERIENCE/ABILITIES:
• Knowledge of nursing/adult home regulations, Medicare, Medicaid and community resources.
• Capacity to assess and provide social services to plan beneficiaries and their representatives.
• Strong oral communication skills and the ability to interact with internal and external staff in a professional and timely manner.
• Must be able to build and maintain collaborative, cooperative, productive relationships with all internal and external customers including beneficiaries and their families, nursing/adult home facility staff, physicians, the health plan and any other stake holders in the community.
• Strong interpersonal mentoring skills.
• Must be comfortable in the nursing/adult home facilities and working with beneficiaries who suffer from multiple comorbidities and/or who are cognitively impaired.
• Knowledge of p.c. use and related software, required.
• Excellent written and verbal skills.

DETAILED DUTIES AND ESPONSIBILITIES – ESSENTIAL FUNCTIONS
• Conduct a Social Service Assessment within 30 days of the beneficiary becoming active in the plan, then annually.
• Conduct a Health Risk Assessment Tool (HRAT) per Family Choice guidelines and ensure documentation and signature in the Family Choice care management record.
• Utilize the results of the HRAT to develop the Individualized Care Plan for each beneficiary to include the 5 required elements of medical, cognitive, functional, psychosocial and mental health.
• Maintain/modify the Individualized Care Plan per Family Choice guidelines and more often as necessary.
• For beneficiaries identified as requiring social service interventions, develops a Social Service intervention which is documented in the Individualized Care Plan. This should include beneficiary specific goals, interventions and progress toward the goal. Goals are all to be SMART (specific, measurable, attainable, realistic and time specific) goals.
• Develop and maintain Individualized Care Plan and coordinate the delivery of care with other members of the Interdisciplinary Care Team.
• Ensure that updates to the ICP are shared with members of the ICT including PCP per Family Choice guidelines and as stated in Model of Care.
• Record and maintain all necessary documentation in the Family Choice Electronic Health Record.
• Assists with obtaining consents upon enrollment and thereafter as needed.
• Assist with surveys.
• Inform beneficiaries and their representatives about their Medicaid benefits and assists with coordination as necessary.
• Assist beneficiaries and/or representatives with insurance, financial and facility related issues.
• Assess beneficiaries/representative for social service needs at the request of the Advanced Practice Provider (APP), PCP or facility social service staff.
• Responsible for completing/reviewing each beneficiary’s Advance Directive Status form at time of initial assessment and keeping the information updated as changes occur. For those beneficiaries who are full codes, a review of the Advance Directive status with possible discussion with beneficiary/caregiver every 6 months with documentation of discussion.
• Provide information via the Advance Directive Status form which assists APPs and PCPs in providing care that is consistent with beneficiary and representative wishes.
• Attend care plan conferences as indicated per Family Choice guidelines and beneficiary/representative needs or request of other interdisciplinary care team (ICT) members.
• Communicate program elements in a clear, concise manner.
• Interface with network facilities, physician and providers.
• Maintain a regular presence at network facilities to establish rapport with key contacts and build understanding and acceptance of the program.
• Provide psychological and bereavement support to beneficiaries and representatives who have experienced a significant loss.
• Maintain contact with beneficiaries/caregivers annually, as per risk stratification, and upon change in status.
• Assist with transfers of beneficiaries to other facilities when necessary.
• Attends meetings as requested.
• Outreach per Family Choice guidelines when a beneficiary is hospitalized.
• Complete all required documentation in a timely manner per company guidelines.
• Perform all other duties as assigned.

Job Type: Full-time
Pay: $60,000.00 - $65,000.00 per year

Benefits: 401(k), 401(k) matching, Dental insurance, Employee assistance program, Flexible schedule, Flexible spending account, Health insurance, Health savings account, Life insurance, Paid time off
Schedule: 8 hour shift, Monday to Friday

To apply, please email direct apply.