Job Description
Bluestem PACE is looking for a full-time Licensed Masters Social Worker (LMSW) to join our team!
Join our team and enjoy outstanding benefits!
At Bluestem Communities, we value our full-time team members and offer a benefits package designed to support both your personal and professional well-being. As a full-time employee you can enjoy the following benefits:
Health and insurance
Health, dental and vision insurance
Flexible Spending Accounts (medical & childcare available)
AFLAC products
Voluntary life insurance
Financial wellness
401(k) plan with company match
Gradifi student loan payment program
Payactiv: Early access to earned wages
Company-paid benefits
Group term life and AD&D insurance
Short-term disability insurance
Employee Assistance Program (EAP)
Time off and perks
Paid Time Off (PTO) and six (6) paid holidays
Bluestem Wellness Center membership
Meal discounts at our dining locations
Our benefits are designed to help you thrive both personally and professionally. Explore the full range of benefits and learn more about how Bluestem Communities can be the right fit for youvisit our Careers page today!
Position Overview:
The primary responsibility of the Licensed Masters Social Worker (LMSW) is to organize and implement social work services for PACE participants and families including but not limited to: participant social work assessment; treatment; and teaching and counseling of participant, caregiver or other appropriate representatives/family to maintain participant support in the community.
Essential Job Functions:
Perform in-person initial assessments for enrollment of potential PACE participants to obtain a complete psycho-social history, to include: descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs.
Collaborate with the interdisciplinary team to develop a comprehensive care plan for each participant.
Conduct in person reassessments of enrolled participants every six months and as needed when participants conditions change.
Maintain regular attendance at and participate in daily Interdisciplinary Team meetings, communicate participant changes and collaborate with team members in care planning decisions and coordination for 24-hour care delivery.
Act as liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with Interdisciplinary Team, day center, and other PACE staff.
Provide ongoing support, counseling, and education to participants and family regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services.
Work proactively to maintain participant housing through intervention with participant, caregivers, and housing. Provide referrals to subsidized housing and assisted living residences. This may involve completing applications, obtaining medical records, accompanying participants to interview assessments and tours if participant has no other support systems.
Assist participant to function at most independent community level possible.
Present requests to Interdisciplinary Team for and coordinate admission/discharge to contracted facilities for temporary respites and permanent placement.
Perform home visits quarterly, or as needed, to assess living environment and support system.
Act as facilitator for meetings with participant, family, caregivers, and community agencies to clarify or problem solve issues, including plan of care. Mediate discussions between all parties.
Perform visits at hospital within 24 hours of admission or on Monday if participant is admitted on Friday or weekend. Coordinate hospital discharges in conjunction with interdisciplinary team and communication with attending physician. Communicate with family or caregivers frequently and as needed to update.
If end of life care is appropriate, actively provide emotional support, grief counseling, education, and funeral/financial planning referral. Facilitate end of life or nursing home placement as needed.
Initiate referrals to external resources with community agencies such as Adult Protective Services, Housing Authority, or public utility companies. Advocate for participants with these entities for purposes of maintaining community stability.
Assist participants and caregivers to complete Medical Durable Power of Attorney (MDPOA), Proxy, and Do Not Resuscitate (DNR) directives as needed.
Attend and actively participate in a variety of organizational meetings related to participant care or daily operations, in-services and community agency meetings.
Act as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
Complete all documentation of clinical service in participants medical records, including: initial assessments; reassessments; change of status; temporary or permanent placements; hospital admissions and discharges; home and nursing home visits; and other significant events according to PACE documentation requirements.
Assist participants with Social Security Income (SSI) and Social Security Disability Insurance (SSDI) application process as needed.
Assist participants and caregivers in filing grievances and appeals.
Assist participants and family in keeping resources within guidelines for Medicaid eligibility and assistance if needed with annual Medicaid application.
Assist participants disenrolling from PACE in coordinating insurance and referrals for other community or facility-based services as desired by the participant.
In the event of termination of Bluestem PACE, the social worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination. Assist participants in obtaining reinstatement in conventional Medicare and Medicaid benefits, transition to other care providers, make referrals to other community-based or facility-based providers, assist in providing the participants medical records to new providers with participant approvals.
Act only within the scope of his or her authority to practice.
Participate in and support Quality Improvement initiatives
Maintain professional affiliations, required certifications and continuing education requirements.
Position specific competencies for the Social Worker will be met prior to assuming participant care.
Serve as part of a rotating on-call pool, requiring availability to respond to calls and provide support outside of regular business hours as needed
Qualifications and Experience:
Must be at least 18 years of age
Must have working knowledge of Microsoft Office Suite.
Masters degree in social work from an accredited school of social work
Active LMSW in the state of Kansas
Current drivers license and proof of auto insurance
Two (2) years of experience working on an interdisciplinary team in a hospital, nursing home or community-based setting is preferable.
Physical Requirements:
Light Work Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently. Requires walking or standing to a significant degree; or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls.
Job Tags
Holiday work, Permanent employment, Full time, Temporary work, Flexible hours,