POSITION IS LOCATED IN SHELBY, NC

Job Summary: Responsible for providing direct social work case management services to the Senior Total Life Care (TLC) participants in a home and community-based model of care in , Cleveland and Rutherford Counties. Provides such social services support as participant screening, case management, counseling, and referral. Links participants with appropriate community resources. Makes In-person Visits to SNFs and private homes of STLC participants, which may necessitate frequent travel in Cleveland and Rutherford counties. Reports directly to the Center Manager and indirectly to the Chief Operating Officer.

Specifications

Education: Minimum of a four-year degree in Social Work with 3 years of experience, preferably in a health and human services field with a geriatric population. Master's Degree from an accredited School of Social Work or Licensed Clinical Social Worker Preferred.

Experience: 2 years experience in a health-related area. Minimum of 1 year experience working with the frail elderly population.

Number and Type of Employees Supervised (optional): None.

Licensure, Registry, or Certification Required: LMSW, LISW, or LCMSW, valid NCDL, and vehicle.

Special Training: Individual therapy skills for geriatric participants, analytical thinking and problem-solving abilities. Experience in linking clients with appropriate community resources. Only act within the scope of his or her authority to practice. Meet a standardized set of competencies for the specific position description established by Senior TLC and approved by CMS before working independently.

Immunizations: Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.

Key Responsibilities:

• Participates in the Interdisciplinary Team's initial assessments, care planning, and periodic re-assessments (minimally every 6 months) of participants’ cases. Assessments are to be completed prior to the scheduled team meeting.
• Maintains current written case management records, including periodic reassessments of program participants.
• Provides individual and family counseling when applicable, develops and leads group counseling and activities.
• Assists and advocates for participants’ access to services. Refers participants and families to appropriate community agencies or facilities, acting as a liaison with such organizations and as an advocate for participants.
• Consults with and advises staff members as to the relationship of social, emotional, and cultural factors to health and medical care, and as to the availability of social services in the community.
• Encourages effective relationships among staff geared to team building and maintenance of a cohesive team.
• Participates in Program and Policy development of the Social Work component.
• Assists with coordination of 24-hour care delivery.
• Documents participant changes appropriately in the medical record and communicates participant changes to team members as needed.
• Updates participants’ care plans appropriately throughout the reassessment period.
• Participates, collaborates, and contributes as a member of the Interdisciplinary team (IDT). Emphasizes teamwork and collaboration in all clinic and Interdisciplinary interactions.
• Supports his/her Interdisciplinary Team (IDT) and promotes unity among the team while interacting with the team, other co-workers, and/or participants.
• Participates in participant care planning including the implementation of SMART goals/interventions for the participants’ care plans and enters all care plan information in a timely manner as per organizational protocols.