Job Abstract

JOB PURPOSE:

The Social Work Care Delivery Field Supervisor, under the direction of the Director of Social Work, oversees and supervises social work services provided at the participant’s home including: supervising, assisting, delegating, and monitoring the social worker’s work and assignments with oversight of social work staff’s advocating, assessing, assisting, collaborating, educating, evaluating, implementing and planning for participants in various aspects of the participant's life. This also includes, but is not limited to, psychological, psychosocial, financial, environmental, and interpersonal matters. Social work engagement takes place in various settings, including but not limited to the participant's home, PACE site, and community settings (hospital, SNF, ALF, etc.)

This role is responsible for monitoring and supporting the social work standards of excellence serving the organization as a member of the management team, working alongside with all departments and employees to support and oversee the day-to-day operations. This role will be responsible for providing orientation and mentorship to new employees and ensuring the ongoing competency of existing employees. The SW Care Delivery Field Supervisor will provide guidance, directions, and assignments, as well as ensure the team delivers best practices in achieving the organization's objectives, goals, and mission. This individual will provide care coordination in a manner that is sensitive to age, gender, sexual orientation, cultural, linguistic, racial, ethnic, and religious backgrounds, and congenital or acquired disabilities.

JOB RESPONSIBILITIES:

• Delegate and assign responsibility and work assignments, as well as supervise assigned personnel in collaboration with the Social Work Manager in a manner that will assure quality care and compliance with the care plan.

• Supervise, instruct, and guide the Social Workers in the delivery of quality services and support in the community.

• Conduct joint visits with Social Workers to provide supervision and verify competencies.

• Assist the Learning Center in designing and developing a structured orientation for new Social Worker employees.

• Act as a resource for the interdisciplinary team.

• Collaborate with all members of the IDT in developing a comprehensive care plan based on member-specific needs, physician orders, UAS-NY CAPS, other IDT assessments, members’ specific parameters, and identified goals that are respectful of member, family, community, and agency resources.

• Organize and manage workload for social workers to ensure the provision of appropriate and maximized social services to participants and authorized representatives.

• Responsible for integration of best practices into the participant’s total care by collaborating with other professional personnel within CenterLight Healthcare, in acute care institutions, skilled nursing facilities, and other community agencies.

• Facilitate educational presentations for the participants in the day health centers. Presentations will be for educational purposes and to promote the social worker’s role in the IDT.

• Attend and actively participate in IDT and care plan meetings. Identify and document, as part of the care plan, and present social work-related concerns and/or issues and outline and discuss appropriate social work interventions and recommendations. Ensure and manage social work interventions are applied by social worker staff and participant-centered goals are met.

• Participate in appropriate continuing education and professional training programs sponsored internally by CenterLight Healthcare and/or applicable outside agencies. Participate in staff enhancement through professional knowledge by attending approved seminars/workshops relevant to the field of Social Work.

• Represent the Social Work department and CenterLight Healthcare at appropriate meetings and conferences in the community.

• Assume responsibility for assignments as needed, will seek guidance from leadership appropriately, and is accountable for meeting their performance metrics and standards by conducting work and performing within their scope of practice.

• Conduct chart audits as assigned on a routine basis and completely in a timely manner.

• Travel is required, which includes but is not limited to participant's homes, hospitals, nursing homes, and other CenterLight sites, and in addition, may be required to cover and manage/supervise Social Work staff in neighboring sites.

• Participate in mandatory in-service education provided by CenterLight Healthcare.

• Conduct social work assessments in lieu of site social workers, as needed, by providing the following:

  • Provide ongoing social work services to participants and their authorized representatives to help them understand and follow care delivery recommendations to assist them with personal and environmental challenges that predispose them toward illness or interfere with obtaining maximum benefit from the PACE program.

  • Educate participants and their authorized representatives in understanding and using community, health, and public services and benefits that help them remain safely in the community (SNAP, SC/DRIE, Medicaid, Medicare, housing, etc.) and assist with making referrals, coordinating services and completing related documents as needed.

  • Ensure timely and appropriate communication and coordination of care during/post hospitalization or other inpatient stays to ensure that a participant's wishes regarding his/her care are followed during that admission. All communication with facilities, hospitals/STR, will be reported to the IDT and documented.

  • Provide social work consultation to participants and authorized representatives as indicated. Provide education on treatment options, including palliative and end-of-life care, and help coordinate services. Arrange bereavement assistance, supportive counseling, or other behavioral health services as needed. Provide caregiver support as needed.

  • Complete biopsychosocial assessments (semi-annual, quarterly revisit, PRN, SOC, ROC, SCIC, SDR), cognitive/emotional status assessments (ie PHQ9, SPMSQ), and other assessments as applicable.  Complete HCP documents and facilitate completion of advance directives, such as the DNR/DNI/DNH/MOLST documents.

  • Assure participant-focused Care Plan psychosocial goals and interventions are applied.

  • Utilize EMR for completion of assessments in a timely manner of 72 hours and other systems as needed.

  • Use case management and clinical skills to help participants and families address and resolve social, financial, and psychological problems related to the participant's health. Ensure timely and appropriate coordination and follow-through of care and services.

• Provide reports as requested by the Clinical/Center Site Director.

• Ensure documentation is completed timely (within 24-72 hrs) and accurately.

• Demonstrating reliable punctuality and attendance.

• Only act within the scope of the individual’s authority to practice.

• Meet a standardized set of competencies for the specific position description established by the PACE organization before working independently.

• All other duties as assigned.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

QUALIFICATIONS:

Education: M.S.W. from an accredited college or university.

Experience:

• Two (2) years of experience in a healthcare setting.

• Experience in home care, PACE setting, MLTC, and/or fieldwork is preferred.

• Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization on working with a frail or elderly population upon hiring.

License: Current active and unrestricted license and registration in NYS as a Social Worker, required.

Additional Requirements:

• Vehicle and current New York State driver’s license preferred. Reliable Transportation is required.

• Knowledge of New York State Department of Health Regulations.

• Be legally authorized (for example, currently licensed, registered, or certified if applicable) to practice in the State in which the healthcare professional will perform the function.

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

• Work outside in varied weather conditions in all areas of the community, using private or public means of transportation.

• Walk to and from patients’ homes.

• Potential exposure to health hazards.

• Work inside in well-lit, heated, and/or air-conditioned offices and/or in varied environmental conditions in the community, which includes participants' homes that the company may not be able to adjust for employee comfort.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.

• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.

• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely and using OSHA guidelines, etc.

• Bending/Squatting – Must be able to safely bend or squat to care for patients, use medical supplies, etc.

• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas Position requires the individual to be able to travel, and walk between sites/locations and work areas throughout the day.

• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.)

• Sight/Visual Requirements – Must be able to visually assess patients, read orders type/write documentation, etc. with accuracy.

• Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.

• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.