Position Summary:

Responsible for the direct social work case management services to the participants of the San Diego PACE program.  Provides such social services support as participant screening, case management, counseling and referral. Follows all policies and procedures of PACE, applicable laws and licensing requirements at all times.

Essential Functions of the Job:

• Participates in the Interdisciplinary Team's initial assessments, care planning and periodic re-assessments (minimally every 6 months) of participant's case.  Assessments are to be completed prior to the scheduled team meeting.  Communicates participant changes to team members.
• Maintains current written case management records,  including periodic reassessments of program participants.
• Provides in-home assessments for all PACE participants.  Completes social service assessments on all participants.
• Coordinates 24 hour care delivery. 
• Provides individual and family counseling, develops and leads group counseling and activities.
• Refers participants and families to appropriate community agencies or facilities, acts as liaison with such organizations and as advocate for participants.
• Encourages effective relationships among staff geared to team building and maintenance of a cohesive team.
• 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.
• Participates in Program and Policy development of Social Work component.
• Documents participant changes appropriately in the medical record.
• Actively participates as a member of the Interdisciplinary Team.  Attends staff meetings and takes part in participant care planning. 
• Maintains a working knowledge of facility service areas including transportation, community characteristics and geography.
• Maintains a networking liaison with other organizations in the eldercare field.  May be requested to represent the agency in contact with human service, health care, and community organization groups and individuals.

Additional Duties and Responsibilities:

• Enhances professional growth and development through participation in educational programs current literature, in-service meetings and workshops.
• Adheres to and models SYHC’s core values and behaviors of Excellence, Empowerment, Integrity and Respect.
• Adheres to SYHC and PACE attendance and punctuality policies and practices.
• Assists participants to fill out Adult Meal Benefit forms upon enrollment and annually.
• Performs other related duties as assigned or requested.

Job Requirements:

Education Required:

Master's Degree from an accredited School of Social Work.

Certifications/Licenses Required:

Valid California driver’s license and access to an insured vehicle. 

Experience and Required Skills:

• Skills in counseling theory and techniques.
• Organization and project management skills.
• Ability to establish and maintain good interpersonal relationships.
• Ability to work independently and meet deadlines.        
• Analytical thinking and problem-solving abilities.                  
• Only act within the scope of his or her authority to practice.        

Verbal and Written Skills Required to Perform the Job:

Excellent oral and written communication skills. 

Equipment Used:

Office equipment, including but not limited to, computers, phones, copy machines, fax machines.

Working Conditions and Physical Requirements:  

Prolonged periods of sitting and standing. Frequent walking. Driving within city. Lifting of no more than 15 lbs. Ability to remain calm and objectively evaluate problems. May be required to work outside of normal working hours. 

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment.  Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.