Social Worker (MSW)

Job Summary

The PACE NEMI Social Worker (MSW) is a member of the PACE NEMI Interdisciplinary Team (IDT) and is
responsible for completing comprehensive initial social work assessments for new PACE NEMI participants
and social work reassessments for existing PACE participants as part of the IDT care planning process.
The PACE NEMI Social Worker provides direct social work and care management services to PACE
participants in concert with the PACE NEMI IDT and current care plan. These services include participant
social work screenings, case management coordination, counseling services, and referrals to community
agencies as appropriate.
The PACE NEMI Social Worker is responsible for being knowledgeable regarding local community
resources and services available to participants and caregivers.
The PACE NEMI Social Worker educates participants, caregivers, and PACE staff on psychosocial factors
and participant/caregiver dynamics impacting participant care.

Position Responsibilities
▪ Participates as a PACE NEMI Interdisciplinary Team member and is responsible for completing a
comprehensive initial social work assessment for new PACE NEMI participants and social work
reassessments on existing PACE participants as part of the PACE NEMI IDT care planning process.
▪ In collaboration with the IDT, develops care plans for social work and delivers social work interventions
to participants identifying and considering the medical, physical, social, and emotional needs of
participants.
▪ Maintains responsibility for the psychosocial well-being of participants through the coordination of
24-hour care delivery working in concert with the IDT. Identifies, provides, and coordinates
participants' medically related social, psychological, and spiritual needs. Implements social work
interventions, case management, individual and caregiver counseling, and comprehensive
psychosocial support.
▪ Consults with and advises PACE NEMI staff members on the relationship of social, emotional, and
cultural factors impacting access to health, medical care, and community resources.
▪ In concert with the IDT, refers participants and families to appropriate community resources, acts as
a liaison with such organizations, and serves as a care advocate for PACE NEMI participants at all times.
▪ Monitors PACE NEMI participants for changes in their health and psychosocial status that require a
social work reassessment. Promptly communicates pertinent changes in participant status to the IDT.

▪ Provides ongoing support and education to participants and caregivers regarding the aging process,
dementia management, grief and loss, end-of-life considerations, disease processes, family dynamics,
and the PACE NEMI service delivery model.
▪ Completes and maintains social work documentation in the PACE NEMI EHR in accordance with the
federal PACE regulation and organizational policy.
▪ Attends IDT and morning meetings and reports on participants’ social status.
▪ Maintains knowledge of Medicaid financial eligibility criteria, including documentation to be
completed.
▪ Maintains knowledge of participant liability and applicable share of cost.
▪ Maintains knowledge of applicable state nursing home Level of Care requirements.
▪ Supports the PACE QI program and participates in PACE QI activities as assigned.

CMS Regulation Requirements and Other Preferred Requirements
▪ Master’s degree in Social Work from an accredited college or university.
▪ Current Licensed Clinical Social Worker (LCSW), LMSW, or LISW if required by the state.
▪ Either have one year of experience working with a frail or elderly population or, in the absence of such
experience, receive appropriate training from the PACE program on working with a frail or elderly
population before providing direct participant care.
▪ Minimum 2 years’ experience in a health-related area.
▪ Demonstrates skills and knowledge as outlined in the social worker competency requirements.
▪ Be medically cleared for communicable diseases and have up-to-date immunizations and vaccines
before engaging in participant care.
▪ Have not been convicted of criminal offenses involving Medicaid, Medicare, other health insurance or
health care programs, or social services programs
▪ Have not been convicted of criminal offenses pertaining to physical, sexual, drug, or alcohol abuse.
▪ Not excluded from participating in Medicare and Medicaid programs.

Additional Skills
▪ Ability to read, analyze and interpret (reports, regulations, periodicals). Write (reports, business
correspondence and manuals). Present information and respond to questions.
▪ Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common
fractions, and decimals.

▪ Ability to solve practical problems and deal with a variety of concrete variables in situations where only
limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral,
diagram or schedule form.
▪ This position has full access to view, alter, retrieve or store individually identifiable health or other
sensitive information, pertinent to accomplishing assigned tasks, and must maintain confidentiality in
accordance with PACE Northeast Michigan Policy.

The information contained in this job description is for compliance with the Americans with Disabilities
Act (ADA) and is not an exhaustive list of the duties performed for this position. Additional duties may be
assigned.
An Equal Opportunity Program/Employer.
Auxiliary aids, services, and alternative format will be made available upon request to individuals with
disabilities.
Michigan Relay Center 1-800-649-3777 (Voice and TDD).
PACE Northeast Michigan is an at-will employer.

To apply:
Please send your resume and cover letter describing your
experience as it relates to the job you are applying for
to: [email protected]