Licensed Masters Social Worker - LMSW

Conduct in-person initial assessments for PACE participant enrollment to obtain psycho-social histories, including cognitive status, social supports, and mental health needs. Collaborate with interdisciplinary teams to develop comprehensive care plans and perform quarterly reassessments or as conditions change. Provide ongoing counseling, education, and advocacy regarding aging, dementia, and end-of-life care while maintaining participant housing through interventions and referrals. Perform home visits to assess living environments and coordinate hospital admissions and discharges within 24 hours of admission. Act as a liaison with community agencies, mediate care discussions, and facilitate end-of-life planning or facility placements. Complete all clinical documentation and assist participants with Medicaid eligibility, Social Security applications, and legal directives. Serve as part of a rotating on-call pool for support outside regular hours.