Position Requirements

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Performs in person initial assessments for enrollment of potential SUNCOAST PACE 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.
2. Conducts in person reassessment of enrolled participants every six (6) months and as needed, per PACE regulations.
3. 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.
4. Acts as liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with Interdisciplinary Team, day center, and other SUNCOAST PACE staff, including volunteers.
5. On an annual basis (during the DOEA 701B assessment -assessment), presents the written participant rights documentation to assigned participants and or caregiver. In the event the participant is unable to understand the information, the Social Worker will ensure the caregiver or representative understands the participant rights. If there is a language barrier the Social Worker will provide the appropriate interpreter.
6. Provides ongoing support, counseling, 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, mental health, substance abuse, PACE model and PACE health services.
7. Works to maintain participant housing through provision of community resource information to participant and caregivers. Will empower participant to function at most independent community level possible.
8. Presents requests to Interdisciplinary Team for and coordinates admission/discharge to contracted facilities for temporary respites, skilled stays, and permanent placement.
9. Acts as facilitator for care planning meetings with participant, family, caregivers, and community agencies to clarify, or problem solves issues regarding the plan of care. Mediates discussions between all parties.
10. Provides referrals to contracted Assisted Living and Skilled Nursing Facilities as needed when participants are no longer able to reside independently in the community .
11. Coordinates Facility discharges in conjunction with Interdisciplinary Team and attending physician. Communicates with family or caregivers frequently and as needed for updates.
12. If hospice care is appropriate actively provides emotional support, grief work, education and funeral/financial planning referral. Collaborates at least monthly with the hospice care team.
13. Assists participants and caregivers to complete Advance Directives including Healthcare Surrogate, Healthcare Proxy, and Do Not Resuscitate (DNR) as needed.
14. Is an active participant in the Interdisciplinary Team and attends IDT, and Plan of Care meetings.
15. Acts as a resource to other team members and day center staff regarding topics such as mental health, substance abuse, health boundaries, psychotherapy, dementia, difficult behaviors, and difficult personalities.
16. Completes and ensures completion of documentation of clinical service, in participant’s medical records including initial and semi-annual assessments, 701B assessments, Medicaid recertifications, change of status, temporary or permanent placements; hospital admissions and discharges, home and nursing home visits and other significant events according to SUNCOAST PACE documentation requirements.
17. Assists with the tracking of annual Medicaid renewals and assists with the renewal process as needed.
18. Assists with the tracking of annual Level of Care (re)certifications and assists the LOC (re)certification process as needed.
19. Develops and Facilitates Support Groups for participants and caregivers as needed in conjunction with the Social Work Team.
20. Assists participants and caregivers in filing grievances.
21. Assists participants and family in coordination with Enrollment Specialist to keep resources within guidelines for Medicaid eligibility.
22. Acts within scope of his or her authority to practice.
23. Follow all SUNCOAST PACE Care policies and procedures and Occupational Safety and Health Administration (OSHA) safety guidelines.
24. Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.
25. Handles potentially infectious specimens with appropriate biohazard precautions, and practices Universal Precautions.
26. Maintains safe working environment. Follows SUNCOAST PACE Care Safety policies and procedures.
27. Participates in and supports Quality Improvement Initiatives.
28. Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.
29. Serve as a chairperson or member of required committees.
30. Initiate and participate in family meetings.
31. Performs other duties as required.

• Must have a valid driver’s license, proof of insurance and have means of transportation.
• Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
• Successfully complete a Competency Assessment upon hire and receive annual competency assessments.

• Master of Social Work (MSW) degree from a school of Social Work accredited by the Council on Social Work Education or has a Masters degree in the counseling field. At least one year of social work or counseling experience in a healthcare setting (the one-year Masters level internship would meet this requirement)

o LCSW, LMHC, LMFT preferred
o Valid Florida State Driver’s License

• Continuing Education: As required for licensure.
• The ability to type 25 wpm is highly preferred. Must receive a passing grade on a pre-employment computer literacy evaluation.
• For field-based positions, employees must have reliable transportation which will enable them to perform tasks and responsibilities in a timely and appropriate fashion. Must provide proof of valid automobile insurance, a copy of which will be placed in the employee’s HR file.

Empath Health values diversity as it strengthens our community and care. We embrace the diversity of cultures, thoughts, beliefs and traditions of our employees, volunteers and people we are honored to serve across our network. Our diverse staff reflects our community and each day, we work to be respectful, sensitive and competent with each other and those in our care. In every journey, we are dedicated to achieving comfort, dignity and exceptional care. Those of all backgrounds are welcome and encouraged to apply with us or seek our care and services.

Our commitment to patient, client, staff and volunteer safety is a cornerstone of a High Reliability Organization with a focus on zero harm. Participation in the seasonal influenza and COVID-19 program is a condition of employment and a requirement for all Empath Health employees.

Drug & Tobacco Free Workplace.

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