Social Worker, LMSW

Position Summary We are seeking a compassionate, organized, and clinically skilled Social Worker, LMSW to provide psychosocial assessment, care management, counseling coordination, participant advocacy, caregiver support, and community-resource coordination for participants. As a member of the Interdisciplinary Team, the Social Worker will complete comprehensive initial social work assessments for new participants and reassessments for existing participants. The Social Worker will identify psychosocial needs, develop social work components of individualized care plans, coordinate interventions, monitor changes in participant status, and advocate for participants and their caregivers throughout the care process. The successful candidate will consider each participant's medical, physical, emotional, social, cultural, spiritual, financial, and family circumstances when developing recommendations and delivering services. The Social Worker will also educate participants, caregivers, and staff regarding aging, dementia, grief and loss, end-of-life considerations, chronic disease, family dynamics, and the care model. This position requires an active New York State LMSW license, at least one year of post-MSW experience, strong electronic documentation skills, and the ability to work independently while contributing effectively to an interdisciplinary healthcare team. Compensation Annual salary of $70,000. Full-time, exempt employment. Additional details regarding benefits, schedule, paid time off, retirement, and insurance eligibility should be confirmed before the public posting is finalized. Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm. Key Responsibilities Psychosocial Assessments Complete comprehensive initial social work assessments for new participants. Conduct required reassessments for existing participants. Complete additional assessments when changes in health, function, living situation, caregiver support, or psychosocial status occur. Evaluate participants' emotional, social, cultural, behavioral, environmental, financial, spiritual, and family circumstances. Assess participant and caregiver strengths, risks, needs, preferences, and support systems. Identify barriers that may affect access to medical care, treatment adherence, safety, independence, or community living. Document findings accurately and communicate significant concerns to the Interdisciplinary Team. Use assessment findings to support individualized care planning. Interdisciplinary Care Planning Participate actively as a member of the Interdisciplinary Team. Collaborate with medical, nursing, rehabilitation, nutrition, transportation, home-care, behavioral-health, and other service professionals. Develop the social work components of each participant's individualized care plan. Recommend interventions addressing medical, physical, social, emotional, cultural, spiritual, and caregiver needs. Participate in participant-review and care-planning meetings. Attend IDT and morning meetings. Report relevant changes in participant social, emotional, family, or environmental status. Monitor the effectiveness of social work interventions. Update recommendations when participant circumstances or care needs change. Help ensure that care plans remain participant-centered, coordinated, and responsive. Case Management and Care Coordination Provide direct social work and care-management services according to the participant's current care plan. Coordinate medically related social, psychological, emotional, and spiritual support. Help participants and caregivers navigate healthcare, benefits, housing, transportation, social-service, and community-resource systems. Identify gaps in services and coordinate appropriate interventions. Maintain ongoing communication with participants, caregivers, service providers, and members of the IDT. Follow up on referrals and confirm that participants can access approved services. Coordinate support across the participant's home, community, and healthcare environments. Advocate for timely and appropriate participant services. Maintain responsibility for the participant's psychosocial well-being through coordinated care delivery. Counseling Coordination and Psychosocial Support Provide or coordinate individual counseling and supportive interventions within the scope of the LMSW role. Assist participants and caregivers with adjustment to aging, disability, chronic illness, loss of independence, and changing care needs. Support participants and families experiencing grief, loss, caregiver stress, family conflict, or emotional distress. Identify behavioral-health concerns requiring additional assessment or referral. Coordinate counseling or behavioral-health resources when appropriate. Help participants and caregivers develop practical coping strategies. Maintain professional boundaries while providing empathetic and participant-centered support. Escalate safety, behavioral-health, abuse, neglect, or crisis concerns according to organizational policy and applicable requirements. Participant and Caregiver Education Educate participants and caregivers regarding the aging process. Provide education regarding dementia management and changes in cognitive functioning. Help participants and caregivers understand disease processes and their psychosocial effects. Provide support and education related to grief, loss, and end-of-life considerations. Explain the service-delivery model. Help caregivers understand participant needs, available supports, and appropriate care expectations. Educate staff regarding participant and caregiver dynamics affecting care. Communicate complex psychosocial topics in clear and understandable language. Reinforce participant choice, dignity, autonomy, and informed involvement in care planning. Community Resources and Referrals Maintain current knowledge of community resources and services available to participants and caregivers. Refer participants and families to appropriate community organizations. Serve as a liaison between participants, caregivers, and community agencies. Coordinate resources involving housing, benefits, behavioral health, caregiver support, social services, legal assistance, food access, transportation, and other community needs. Track referrals and follow up on service access. Identify barriers to obtaining services and collaborate with the IDT to address them. Build and maintain productive relationships with community agencies and service-delivery partners. Advocate for participant access to appropriate resources. Participant Advocacy Serve as a consistent advocate for participants. Promote participant rights, preferences, dignity, safety, and self-determination. Help ensure participant and caregiver concerns are communicated to the appropriate team members. Identify circumstances in which a participant's social environment may affect care access or outcomes. Support participants through changes in health, living arrangements, caregiver availability, or service needs. Help resolve barriers involving healthcare systems, benefits, community programs, or family dynamics. Communicate concerns regarding potential abuse, neglect, exploitation, unsafe living conditions, or unmet needs according to policy and applicable requirements. Monitoring and Reassessment Monitor participants for changes in health, psychosocial status, behavior, emotional well-being, family support, and living circumstances. Identify changes requiring social work reassessment. Promptly communicate significant changes to the Interdisciplinary Team. Review whether current interventions remain appropriate and effective. Update social work goals and interventions as necessary. Monitor caregiver availability and stress. Identify emerging risks that could affect a participant's ability to remain safely in the community. Maintain timely follow-up on unresolved psychosocial concerns. Medicaid and Financial Eligibility Support Maintain working knowledge of Medicaid financial eligibility requirements. Understand the documentation generally required to support financial eligibility. Maintain knowledge of participant liability and applicable share-of-cost requirements. Help participants and caregivers understand applicable documentation or financial-process requirements. Coordinate with internal and external resources regarding eligibility and participant financial responsibilities. Identify missing information that could affect program eligibility or continued participation. Escalate complex eligibility questions to the appropriate subject-matter resource. Protect participant financial and personal information. Nursing Home Level-of-Care Requirements Maintain knowledge of applicable New York State nursing home Level of Care requirements. Understand how participant medical, functional, and psychosocial needs relate to program eligibility and care planning. Support the collection and communication of psychosocial information required for participant review. Coordinate with clinical and administrative team members regarding relevant eligibility or reassessment needs. Maintain accurate records supporting participant care and program requirements. Electronic Health Record Documentation Complete social work documentation in the Electronic Health Record. Maintain timely, accurate, complete, and objective clinical records. Document assessments, reassessments, interventions, referrals, counseling coordination, participant status, and follow-up activity. Record relevant participant and caregiver communications. Ensure documentation complies with federal regulations and organizational policy. Maintain participant confidentiality. Correct or update records promptly when necessary. Support continuity of care by providing clear and useful documentation to the Interdisciplinary Team. Quality Improvement Support the Quality Improvement program. Participate in assigned quality-improvement activities. Identify opportunities to impr