Care Guide Partners PACE is a part of Hosparus Health. As a Program of All-Inclusive Care for the Elderly (PACE) provider, we work to empower people 55 and older with the support they need to stay in the homes they know and love as they age. PACE helps seniors who need nursing home-level care maintain their independence by providing all the medical care and support services they need to continue living comfortably and safely at home.
CSW or LCSW
Full time, day shift
Position Summary:
The PACE Social Worker provides social work services to participants and families/caregivers as assigned including screening and assessments, case management, emotional support, counseling, support related to legal affairs, assistance in planning for caregiving and financial services. Provides other social services support and guidance as needed. The social worker plans, implements and documents individualized social services plans of care in accordance with the interdisciplinary team, policies and expectations of the PACE program according to regulatory standards.
Position Duties & Responsibilities:
- Provides comprehensive social services support for participants including but not limited to screening and assessments, case management, emotional support, counseling, support related to legal affairs, assistance in planning for caregiving and financial services.
- Develops and leads group counseling and activities.
- Refers participants and families to appropriate community agencies or facilities, acts as a liaison with such organizations, and as an advocate for participants.
- Consults with and advises staff members regarding the relationship of social, emotional and cultural factors to health and medical care, and as to the availability of social services in the community.
- Participates as a member of the Interdisciplinary Team (IDT) responsible for social services evaluations and development and implementation of the individualized social services plan of care (POC) in accordance with PACE policies, procedures, expectations and regulations.
- Reviews/revises the POC in coordination with the IDT and per regulatory requirements as participant status changes and as driven by needs identified as significant by the participant/family/caregiver.
- Observes each participant for changes in physical, mental, emotional and social functioning and reports such changes to the IDT.
- Identifies and provides for educational needs of the participant/family/caregiver.
- Participates in center quality improvement activities.
- Knowledgeable of participant rights and ensures an atmosphere which allows for the privacy, dignity and well-being of all participants in a safe, secure environment; utilizes established mechanisms for management of ethical issues in participant care.
- Works with interdisciplinary teams to assure effective, cost-efficient care.
- Assists participants and caregivers in filing grievances.
- Completes documentation accurately and in a timely manner.
- Other projects and duties as assigned.
Position Qualifications:
- Licensed in state of Kentucky as Certified Social Worker (CSW) or Licensed Clinical Social Worker (LCSW).
- Minimum 1 year of experience working with a frail or elderly population or must receive appropriate training upon hire. Two years social work experience in healthcare setting preferred.
- Must maintain CPR certification.
- Must have flexibility to travel to participant homes and other locations within service area.
- Proficiency with technology-based tools, including electronic medical record.
- Able to work independently and as an effective member of a team.
- Excellent communication skills, with ability to communicate with internal stakeholders at all levels of the organization and external stakeholders from varied backgrounds.
- Excellent organizational skills; able to multitask and maintain numerous initiatives with time sensitivity.
- Working knowledge of principles and practices of healthcare, healthcare systems, managed care, Medicare and Medicaid benefits and regulations.
- Knowledge of safety and infection control requirements for healthcare facilities.
Job Description for Nurse Practitioner
Department: Medical Team
Position reports to: Sr Nurse Practitioner
Position supervises: None
FLSA Status: Exempt
EEO Category: Professionals
Pay Grade: 12
Position Summary:
Under the general supervision of the Medical Director, the Nurse Practitioner for Medical Services plans, directs, and evaluates patient medical care of assigned patients in designated facilities. Examines and treats chronic and urgent episodic illnesses, injuries, accidents, and other injuries/ illnesses. Performs selected laboratory testing, referrals to physicians, as needed, writes prescriptions, and performs procedures within the scope of expertise, protocols and available equipment. Work in collaboration with the facility’s medical director, attending physicians and other care providers to provide care and treatment services for all patients.
Position Duties & Responsibilities:
- Provides consulting and attending patient care services, including medically-necessary visits with appropriate documentation, coding and billing capture, medical orders, prescriptions, family meetings, and coordination of care with facility staff and attending physicians.
- Demonstrates clinical expertise in advanced nursing practice. Performs services within Scope of Practice. Practices medicine in alignment with evidence-based medical recommendations, regulatory requirements and formularies.
- Performs procedures within the scope of expertise, protocols and available equipment.
- Maintain open communications with patients, families and/or responsible parties, facility staff and attending physicians.
- Maintain confidentiality and upholds highest level of professionalism.
- Schedules initial and follow-up visits, as needed, and aligned with AMDA White Paper on Medical Necessity Guidelines and Federal Guidelines.
- Collaborates with interdisciplinary care providers and facility staff to identify patients’ proactive medical needs and help develop an appropriate plan of care.
- Confers with patients and their family and/or responsible parties regarding the patient’s status.
- Assesses patients prior to discharge from facility or other location of practice to home or other place of residence and coordinates a seamless transition of care with outside providers.
- Attends to patients for selected physical examination, diagnosis and treatment of both chronic diseases and urgent episodic illnesses and injuries.
- Participates in on-call rotation as directed by Medical Director to ensure 24/7 coverage of patient needs.
- Performs and documents re-certification face-to-face visits and attestations in a timely manner.
- Establishes a collaborative practice agreement with the Medical Director regarding prescriptive authority.
- Collaborates with the Medical Director for prescription of controlled substances and management of complex cases that are outside the scope of advanced nursing practice.
- Complies with state laws for prescription of controlled and non-controlled medications.
- Maintains provider status with third party payers, as applicable.
- Performs and documents required face-to-face re-certification visits in full compliance with Medicare regulations.
Organizational Duties & Responsibilities:
- Supports the mission, vision, values and values in action of Care Guide Partners.
- Facilitates and adheres to policies and procedures and Hosparus Health code of conduct, which includes our values in action.
- Supports all functions that attain and maintain accreditation and compliance with regulatory agencies.
- Exhibits effective communication skills including proper use of agency communication systems.
- Participates in appropriate professional development programs to attain and maintain competency.
- Effectively manages financial and physical resources to achieve the mission of the organization.
Position Qualifications:
- MSN or higher-level Adult Nurse Practitioner required.
- Licensure (or eligibility for licensure) for advanced nursing practice in KY, including DEA and controlled substance permits, required.
- Minimum of one year experience in full time advance nursing practice required. Previous experience in skilled nursing or experience working with geriatric population preferred.
- Fulfill requirements of on-call duty policies.
- Proficiency using technology-based tools, including electronic medical record and other software programs.
Essential Physical Abilities:
- Above average skills in reading, writing and speaking English.
- Ability to move, push, pull and lift a minimum of 50 pounds unassisted using appropriate lifting techniques and/or devices.
- Close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.
- Regularly required to talk or hear.
- Frequently required to use hands and fingers to handle, reach or feel and manipulate objects or controls.
- Frequently required to sit or stand for long periods of time.
- Ability to walk distances, as well as stoop, bend, kneel, crouch and walk up and down stairs on a frequent basis.
Working Conditions:
- Care and services are provided wherever the patient calls home, which may include residential settings and/or facility-based settings. Work will be performed primarily indoors but will require driving to care settings.
- Reasonably anticipated risk for exposure to blood or other potentially infectious materials in the performance of routine duties.
EMPLOYEE ACKNOWLEDGEMENT:
I can perform the above essential job duties with or without reasonable accommodations.
( ) Yes ( ) No ____________ Initial Here
Hosparus Inc. is an Equal Opportunity Employer. In compliance with the Americans with Disabilities Act, and other state and federal laws, Hosparus Health will provide reasonable accommodations to qualified individuals with disabilities and encourages both prospective employees and incumbents to discuss potential accommodations with the employer. Employees should immediately notify Human Resources if, at some time in the future, they need an accommodation or are no longer able to perform any of the job duties, with or without accommodation. This job description is not considered an employment agreement or contract. The specific statements shown in each section of this job description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform the position. Management has the exclusive right to alter job responsibilities at any time without notice to meet business and agency needs, except as required by law.
Employee Printed Name: _________________________________
Signature: _______________________________ Date: ________________
