Social Worker

GENERAL SUMMARY

Essential Responsibilities

• Participates on the IDT’s initial assessments, care planning and on-going re-assessments of participant care.
• Attends IDT meetings; actively participates in team meetings by sharing pertinent information, providing follow up to assigned tasks and helps to develop participant’s plan of care.
• Completes all assigned assessments – (initial, semi-annual, annual, service request and/or significant event).
• Assesses the psychosocial needs of the participant and provides supportive counseling, working collaboratively with behavioral health providers.
• Facilitates hospital, rehabilitation and nursing home (NH) admissions and discharges as determined by the Interdisciplinary Team. Ensures that PASRR documentation is completed for NH admission.
• Assists in the conversion process of the participant from community to long-term care. Works collaboratively with Medicaid Specialist, skilled nursing facility, and participant’s caregiver to complete conversion.
• Arranges and facilitates family meetings, as needed.
• Refers participants and families to appropriate community services and acts as liaison and/or advocate with community organizations for participants.