GENERAL DESCRIPTION:

Under the direct supervision of the Director of Program Communication and Growth and assisted by the Intake Manager, the Enrollment Team Social Worker works with the Enrollment Team to complete all required Social Service evaluations of MN-LOC evaluation packet for all applicants interested in enrolling in the Program of All‐Inclusive Care for Elderly (PACE)/Bienvivir. Serves as a community liaison with local community referral sources and is responsible for the coordination and completion of the Social Work portion of the visitor’s application process, to include social work general assessments, financial, medical and SASO applications, to the State of Texas.

RESPONSIBILITIES:

• Works in conjunction with the Intake Team (Customer Service Representatives, Intake Coordinators, Intake Nurse, Intake Manager, Physician and Medicaid Eligibility Workers) during the enrollment process to initiate and process both financial and medical applications for all potential
• Completes Home Visit(s) as needed during the enrollment process. Duties to include, but not limited to: data collection, initial MMSE and assessments review of financial and medical applications, explanation of denial process and appeals hearing
• Will present to Interdisciplinary Team by providing updates regarding enrollment status of applicants: specifically, to medical and financial eligibility, and SASO processing updates.
• Serves as a liaison to the Visitor, their family and/or caregivers via home visits, family conferences and telephone contacts; communicates appropriate information as
• May provide referrals to Visitors for community-based outreach crisis counseling and intervention; advocacy, and case
• In conjunction with the Intake Team, schedules and completes the general social work assessments (MMSE and assessment) of the MC-LOC packet, Health Care Wishes, and Enrollment Packet explanations for all applicants. Once a Visitor is enrolled with Bienvivir, the Social Worker will transition each case to the Center-based assigned Social
• Visitor circumstances may require initial assessments to be completed during a Home
• Conducts and completes a Home Safety Screen and review of the applicant’s living Based on observations, the Social Worker may make recommendations to the IDT for applicant DME needs.
• Provides education to Visitor and their family and/or caregivers regarding Advanced Directives, Medical Power of Attorney, and Guardianship. May initiate and assist with completing Advanced Directives, Medical Power of Attorney, and Guardianship as
• Collaborates with Enrollment Team Physician and Nurse to refer Visitor’s and or family/caregivers to placement options when necessary.
• Collaborates with Intake Team to complete weekly follow‐ups and communication with applicants their family and/or caregivers throughout the enrollment process.
• Serves as a liaison and advocate for Visitors and their family and/or caregivers with community-based agencies such as Social Security Administration, HHSC, Probate Court and HHSC
• Coordinates with the Enrollment Team Nurse and center-based Social Worker/New Enrollee guide introduce Visitor’s to each IDT member and tours the visitor through various departments areas of the center.
• Interprets the social aspects of the Visitor’s psycho-social condition to the IDT during the PCP
• Reviews and completes the Enrollment Contract ‐ upon notification by HHSC that a Visitor has met all State requirements for enrollment and is approved for Bienvivir PACE
• Establishes and maintains a positive relationship with Bienvivir contracted Assisted Living Facilities to ensure that any Visitor placement needs will be met appropriately and on a timely basis, if needed.
• In coordination with the Outreach Department may participate and present the philosophy of community‐based long‐term care for the elderly as it is delivered by PACE during health‐fairs, outreach events, community and professional presentations and other healthcare-related events.
• Provides appropriate documentation for internal and external reporting purposes as requested by supervisor.
• Familiarizes self with, understands and is compliant with Bienvivir policies and
• Completes mandatory initial and ongoing training as
• Maintains current Social Work licensure and licensure training hours as required by the Texas Board of Social
• Other duties as assigned by supervisor.

KNOWLEDGE, SKILLS, AND ABILITIES:

• Knowledge and experience working with the geriatric population and associated family
• Knowledge of referral systems for community services that ensure basic needs are met, (i.e... housing, utilities, food pantries, transportation, health insurance, etc.)
• Must possess a working knowledge of case management, Social Work theory, and
• A dependable individual with strong organization and problem-solving
• Must possess a strong knowledge base and keen understanding and appreciation of the
• Possess the ability to effectively communicate the philosophy of community‐based long‐term care for the elderly as it is delivered by PACE/Bienvivir.
• Work within the ethical principles of the Social Work Code of Ethics and exhibit appropriate professional behavior when interacting with visitors, families, colleagues and members of the community.
• Adaptable individual with the ability to work as a member of an interdisciplinary team and able to communicate (both verbally and written) effectively with staff, visitors and family
• The ability to accept supervision and constructive correcting in an appropriate
• Bilingual (fluent in English and Spanish)
• Possess strong computer skills: proficient using MS Office Suite.
• Must have dependable transportation, a valid driver’s license, and automobile insurance (liability).

QUALIFICATIONS / REQUIREMENTS:

• A graduate of an accredited university with a bachelor’s degree or master’s in social work and licensed by the Texas State Board of Social Worker
• One year of experience providing Social Services to a frail elderly population