Social Worker, MSW

Responsibilities The Social Worker, MSW plans, organizes and implements social work services to participants and their caregivers in accordance with InnovAge policies and all applicable regulations. Conducts psychosocial assessments, participates in care planning and acts as a liaison between the participant and the interdisciplinary team. This role requires being on-site at the center and field-based work, including visits to participants’ homes and other locations, to ensure continuity of care and support. Essential Functions and Work Responsibilities Functional Category: Assessment & Care Planning Conducts initial psychosocial assessments (including SLUMS, PHQ-9, housing, food, financial security, MDPOA/decision-maker status). Completes in-person reassessments at least every six months or as required. Performs in-home visits as required by regulations or as indicated Participates in IDT meetings, morning huddles, mini-teams, and PDPM meetings to ensure coordinated care. Facilitates and documents participant care conferences, family meetings, and facility partnership meetings. Participates in discharge planning and plan of care development, ensuring problems, interventions, and goals are well defined. Supports participants transitioning between residences or care facilities, including arranging transportation and coordinating moves when no support system is available. Functional Category: Case Management & Care Coordination Serves as primary liaison between participant/family and the IDT, facilitating communication and resolution of care issues. Coordinates respite SNF, ALF admissions, including transportation and discharge planning. Documents housing encounters in EPIC Collaborate with comfort care team for end-of-life activities Assists participant’s family with end-of-life coordination Collaborates with RN Case Management on hospitalizations, and provides psychosocial input May serve as back-up to RNCM. Reviews participant/family concerns with Ombudsman and escalates facility quality concerns; maintains admission holds on facilities with care issues and manages urgent rehousing when contracts terminate. Coordinates guardianship process for participants lacking decision-making capacity without a surrogate. Obtains SNF/ALF updates for IDT, manages respite scheduling, and ensures placement transitions are supported. Provides options counseling when appropriate Assists participants who are disenrolling with timely referrals to external services and completion of disenrollment paperwork. Functional Category: Psychosocial Support & Advocacy Provides counseling and psychosocial support in coordination with behavioral health for participants and caregivers as indicated Completes comfort care assessments and provides guidance on transitions to end-of-life services. Advocates for participants living in unsafe housing conditions Contributed to RCAs development, incident reporting, and…