San Jose CaliforniaFulltimeReporting to the Social Work Manager the Social Worker maintains a caseload of participants working in close coordination with the IDT. In addition to delivering standard social work services such as psychosocial assessments care planning counseling and case management the Social Worker functions as a liaison between the participants family members support network and care team as appropriate.Essential Job Duties:Conduct Social Work assessments to determine the psychosocial needs preferences and goals of the participants and actively participate in IDT meetings to develop participant care plansDeliver and document social work interventions as agreed upon in the participants care plans including but not limited to arranging necessary resources and services assisting with care transitions providing individual as well as group counseling and case managementWork with the primary care physician and other members of the care team to guide smooth care transitions between settings (e.g. hospitals skilled nursing facilities home etc.)Initiate coordinate and facilitate care conference meetings to ensure the highest level of care coordination among other care team members participants and other people within the participants support network (family informal caregivers etc.)Provide discharge planning when participants disenroll from the programJob Requirements:Masters Degree in Social Work (MSW) requiredMinimum of one (1) year of experience with a frail or elderly populationPrevious experience coordinating and facilitating care conference meetingsPrevious experience assisting people with behavioral health & substance abuse issues preferredSKILLS AND CERTIFICATIONS MSW1 year of experience