Social Worker (PACE) Intake Coordinator
at Volunteers of America

Date Posted: 3/19/2020

Job Description

Under the supervision of the Center Manager plans, organizes and implements social services to Senior CommUnity Care participants and families. Responsibilities include but are not limited to: assessment, treatment, teaching and counseling to participant, caregiver or other appropriate representatives. The Social Work interventions could include individual participant contacts; appropriate collateral contacts; participant and family education, assessment and counseling; provision of resources; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The Social Worker is the liaison between the Interdisciplinary Team (IDT), caregiver representatives, and community agencies.


  • Performs in person initial assessments for enrollment of potential Senior CommUnity Care participants to obtain a complete psychosocial history, which may include descriptions of cognitive status, social supports, family dynamics mental health and substance dependency and other issues and needs. Coordinates with the Interdisciplinary Team to develop a comprehensive plan of care for each participant.
  • Conducts in person re-assessment of enrolled participants every six (6) months and as needed.
  • Functions as a member of the Interdisciplinary Team. Maintains regular attendance at and participates in Interdisciplinary Team meetings; communicates participant changes, collaborates on plan of care decisions and coordination for twenty-four (24) hour care delivery.
  • Provides ongoing support, counsel, 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.
  • Presents requests to Interdisciplinary Team for and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement.
  • Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem solves issues regarding the plan of care. Mediates discussions between all parties.
  • If hospice care is appropriate actively provides emotional support, grief work, education and funeral/financial planning referral. Facilitates hospice 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. Advocates with these entities for purposes of maintaining community stability.
  • Assists participants and caregivers to complete Medical Durable Power Of Attorney (MDPOA) Proxy, and Do Not Resuscitate (DNR) directives as needed.
  • Attends and actively participates in a variety of organizational meetings related to participant care, including but not limited to: Morning Meeting, Intake and Assessment Meeting, various in-services and community agency meetings.
  • Acts as a resource to other team members and day center staff regarding topics such as dementia, difficult behaviors, and difficult personalities.
  • Completes and ensures completion of documentation of clinical service, in participant’s medical records including initial assessments, re-assessments, change of status, temporary or permanent placements; hospital admissions and discharges, home and nursing home visits and other significant events according to Senior CommUnity Care documentation requirements.
  • Assists participants and caregivers in filing grievances.
  • Acts within scope of his or her authority to practice.
  • Follow all Senior CommUnity Care policies and procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
  • Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.
  • Maintains safe working environment. Follows Senior CommUnity Care Safety policies and procedures.
  • Participates in and supports Quality Improvement Initiatives.
  • Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.
  • Performs other duties as required.

Additional Essential Functions:
1. Meet or exceed monthly enrollment goals.
2. Responsible to ensure completion of State of Michigan Level of Care Determination (LOCD) assessment tool.
3. Submits input to the team on care plan based on the intake information.
4. Coordinates in conjunction with other intake staff, timely follow-up with referral sources, families and participants through phone contact, letters, and all other appropriate documentation.
5. Utilizes nursing assessment skills to determine eligibility of the potential participant for the PACE program.
6. Completes timely intake and enrollment documentation.
7. Updates appropriate tracking tools to depict prospective participant status.
8. Participates in IDT and other related meetings and activities.
9. Gathers all necessary documents for Medicaid application and completes the application in a timely manner.
10. Work closely with DHHS eligibility specialist and marketing team to ensure Medicaid and Medicare eligibility upon intake.
11. Exhibit professionalism in the community as a representative of Senior Community Care of Michigan (SCCM).
12. Responsible for developing effective working relationships with DHHS, MDHC, CMS and all other agencies related to the intake process.
13. Maintain confidentiality of all PACE information pertaining to potential and current participants’ issues or business practices.
14. Completes other assessments as needed to determine eligibility (e.g. SLUMS).
15. Able to work flexible hours as needed to complete the requirements of this position.

Job Requirements


  • Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
  • Must have a valid driver’s license and have means of transportation.
  • Must clear background check.
  • Education: Masters Degree from an accredited school of social work required. Be legally authorized, currently licensed, registered or certified if applicable in the state of employment.
  • Experience: A minimum of one year’s experience working with frail or elderly population required. Experience working on a multi-disciplinary team in a hospital, nursing home or community-based setting is preferable.
  • Skills and Knowledge:
    • Experience with frail/chronically ill elderly people.
    • Ability to provide psychosocial assessment and individual, family and group counseling.
    • Effective verbal/written communication skills with the ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.
    • Training and/or mentoring experience and ability to complete performance objectives, measures and evaluations.
    • Good public speaking skills with all size groups.
    • Ability to communicate clearly and effectively verbally and written.
    • Ability to utilize computers and other electronic devices for tasks such as timekeeping, in-servicing and documentation.
    • Only acts within the scope of his or her authority to practice. Must meet a standardized set of competencies for the specific position description established by Senior Community Care and approved by CMS before working independently.

 EOE M/F/Vets/Disabled

Job Snapshot

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