Social Worker (MSW)

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 Worker plans, organizes and implements social work services to participants and their caregivers in accordance with Seen Health policies and all applicable regulations. As an integral member of an Interdisciplinary Team, the social worker performs psychosocial assessments, develops and implements plans of care, conducts counseling and case management, and facilitates communication between the participant, family, caregivers, PACE staff, and provider support network, as appropriate.

Responsibilities

Conduct Social Work assessments to determine the psychosocial needs, preferences and goals of the participants and actively participate in IDT meetings to develop participant care plans. Deliver and document social work interventions as agreed upon in the participants’ care plans including but not limited to arranging necessary resources and services, assisting with care transitions, providing individual as well as group counseling and case management. Completes initial assessments, re-assessments, and care plan updates for participants while continually evaluating the participants' social service needs and caregiver support needs.

Participates in regularly scheduled behavioral management meetings with other mental health professionals. ). Assists physician, or intermediate care provider, and other team members in understanding the significant social and emotional factors related to participant health problems.

Acts as a resource to other team members and staff regarding topics such as dementia, difficult behaviors, and difficult personalities. Supports the IDT in establishing behavior management plans. Strive for continuous growth and development of cultural competency exhibiting an understanding, awareness, and respect for diversity.

Maintains accurate and timely documentation and paperwork including participants’ electronic medical records according to policies and procedures. Provides referral support to community resources and participates in inter-agency coordination of care. Develops and maintains working relationships with community agencies, such as the Department of Social Services, psychiatric facilities, skilled nursing facilities, hospitals, social agencies, and may participate in hospital and/or SNF discharge planning.