About Seen Health At Seen Health, we are revolutionizing the way senior care is delivered through the PACE (Programs of All-Inclusive Care for the Elderly) model. Backed by top VCs, Seen Health is a culturally-focused, technology-enabled healthcare organization that integrates comprehensive medical care and social support with a high-touch, interdisciplinary approach. Our mission is to empower seniors to age-in-place with dignity and provide their families peace of mind.

We are building upon a proven Home and community based services model to create a culturally-competent and scalable PACE program. We are also building a comprehensive operating system focused on data and workflows that span across systems, processes, people, and care contexts. We want to empower our clinicians and staff with tools that deliver relevant data at the time and site of care and enable them to deliver exceptional care to our participants, which improve clinical outcomes, participant & provider satisfaction, and ultimately our strength as an organization.

We are a mission-driven, multidisciplinary team with deep healthcare, technology, and operations expertise, each inspired by our own personal stories of caring for seniors in our lives. Our name, Seen Health, was chosen to reflect our commitment to provide the highest standard of care to underserved older adults while respecting and incorporating their individual beliefs, heritage, and values, so that they can truly be seen .

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.

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.