Job Description

We are seeking a compassionate and experienced Social Worker to support older adults through individualized counseling, care coordination, case management, and community resource referrals. This role works closely with an interdisciplinary team to assess participant needs, develop care plans, advocate for participants and their families, and help ensure access to appropriate healthcare and social services. Experience in a PACE program or a similar senior care setting is highly preferred.

Responsibilities/ Job Duties: 

• Participate in interdisciplinary team meetings to support participant assessments, care planning, and ongoing evaluations of individual needs.
• Conduct participant home visits as needed to assess living conditions, social support systems, and access to care.
• Maintain accurate and timely documentation, including progress notes, assessments, care plans, and required reports in participant medical records.
• Provide individual and family counseling, as well as facilitate group counseling sessions when appropriate.
• Connect participants and their families with community resources, social services, and other support programs.
• Advocate for participants and collaborate with community organizations to coordinate services and address social, emotional, and cultural needs.
• Support participants and families through transitions in care, including referrals to primary care providers and community resources when services end.
• Collaborate with interdisciplinary team members and other professionals to promote coordinated, participant-centered care.
• Provide guidance to staff regarding the impact of social, emotional, and cultural factors on health outcomes and access to services.
• Contribute to program development, policy improvements, and initiatives that enhance the quality and effectiveness of social work services.
• Monitor participant needs and service utilization while supporting productivity, quality, and customer service goals.
• Maintain a safe, respectful, and supportive environment for participants, staff, and visitors by following established safety procedures.
• Deliver age-appropriate services that address the unique needs of older adults and other individuals requiring additional support.
• Build positive relationships with participants, families, caregivers, and community partners to improve service delivery and overall care coordination.
• Participate in community outreach and engagement activities to strengthen connections with local service providers and organizations.
• Follow organizational policies, procedures, confidentiality standards, and applicable professional guidelines.
• Perform other duties as assigned.

Minimum Education and Experience Qualification Requirements: 

• Master’s degree in Social Work (MSW) from an accredited institution.
• At least one year of social work experience, preferably in a healthcare or community-based setting.
• At least one year of experience working with older adults or other populations with complex care needs.
• Knowledge of social work principles, case management, counseling techniques, and community resources.
• Ability to collaborate effectively with interdisciplinary teams, participants, families, and external service providers.
• Strong communication, organization, documentation, and problem-solving skills.
• Ability to understand and address the social, emotional, cultural, and environmental factors that influence health and well-being.
• Current California driver’s license.
• Current CPR/BLS and First Aid training, or ability to meet applicable requirements.
• Ability to meet required health screening and employment clearance standards.

Schedule/ Shift: Monday through Friday, 8:00 AM–5:00 PM. 

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.