Medical Social Worker – On Lok PACE

About the role

The Medical Social Worker at On Lok PACE at the Institute on Aging (IOA) provides psychosocial assessment and therapeutic counseling to a caseload of clients with complex medical and psychosocial problems. The role serves as the primary liaison between participants, their families and the interdisciplinary care team.

Key responsibilities

• Conduct in-depth biopsychosocial assessments covering physical and mental health, finances and environment, and develop a participant-centered care plan integrated with the interdisciplinary team.
• Join primary care providers and registered nurses in a core primary care team and direct the involvement of other disciplines.
• Coordinate care for participants with complex needs, monitor transitions of care and support safe discharge planning.
• Provide supportive counseling, crisis intervention, advocacy, problem solving and therapeutic interventions for illness, grief and loss.
• Facilitate family and care team meetings on end-of-life planning, health care wishes and goals of care.
• Partner with community providers, facilitate enrollment of participants in On Lok PACE, and refer to behavioral health services.
• Advocate for mental health, co-occurring substance use and chronic housing instability issues, and evaluate participants' ability to stay safely in the community.
• Document care in the electronic health record, educate participants and their support systems about resources, and take part in quality improvement and data collection.

Required profile

• MSW from an accredited school of social work.
• At least one year of professional experience working with frail elderly.
• At least one year of experience in an interdisciplinary care model.
• Understanding of the medical and psychosocial problems of functionally impaired adults and the frail elderly.
• Bilingual Cantonese or Spanish preferred.

Required skills

• Exceptional communication and presentation skills with health professionals and support systems.
• Detail-oriented, with good problem-solving and prioritization skills.
• Computer literacy preferred.
• Supervision toward LCSW licensure is provided; licensure is not required.

What we offer

• Salary range of $87,260 - $104,289 per year, depending on experience and education.
• Continuing education and in-service training in medical social work, gerontology and case management.