Social Worker, LMSW

Position Summary We are seeking a compassionate, organized, and clinically skilled Social Worker, LMSW to provide psychosocial assessment, care management, counseling coordination, participant advocacy, caregiver support, and community-resource coordination for participants. As a member of the Interdisciplinary Team, the Social Worker will complete comprehensive initial social work assessments for new participants and reassessments for existing participants. The Social Worker will identify psychosocial needs, develop social work components of individualized care plans, coordinate interventions, monitor changes in participant status, and advocate for participants and their caregivers throughout the care process. The successful candidate will consider each participant's medical, physical, emotional, social, cultural, spiritual, financial, and family circumstances when developing recommendations and delivering services. The Social Worker will also educate participants, caregivers, and staff regarding aging, dementia, grief and loss, end-of-life considerations, chronic disease, family dynamics, and the care model. This position requires an active New York State LMSW license, at least one year of post-MSW experience, strong electronic documentation skills, and the ability to work independently while contributing effectively to an interdisciplinary healthcare team. Compensation Annual salary of $70,000. Full-time, exempt employment. Additional details regarding benefits, schedule, paid time off, retirement, and insurance eligibility should be confirmed before the public posting is finalized. Proposed Schedule: 40 hours per week. Monday-Friday 8am-4:30pm. Key Responsibilities Psychosocial Assessments Complete comprehensive initial social work assessments for new participants. Conduct required reassessments for existing participants. Complete additional assessments when changes in health, function, living situation, caregiver support, or psychosocial status occur. Evaluate participants' emotional, social, cultural, behavioral, environmental, financial, spiritual, and family circumstances. Assess participant and caregiver strengths, risks, needs, preferences, and support systems. Identify barriers that may affect access to medical care, treatment adherence, safety, independence, or community living. Document findings accurately and communicate significant concerns to the Interdisciplinary Team. Use assessment findings to support individualized care planning. Interdisciplinary Care Planning Participate actively as a member of the Interdisciplinary Team. Collaborate with medical, nursing, rehabilitation, nutrition, transportation, home-care, behavioral-health, and other service professionals. Develop the social work components of each participant's individualized care plan. Recommend interventions addressing medical, physical, social, emotional, cultural, spiritual, and caregiver needs. Participate in participant-review and care-planning meetings. Attend IDT and morning meetings. Report relevant changes in participant social, emotional, family, or environmental status. Monitor the effectiveness of social work interventions. Update recommendations when participant circumstances or care needs change. Help ensure that care plans remain participant-centered, coordinated, and responsive. Case Management and Care Coordination Provide direct social work and care-management services according to the participant's current care plan. Coordinate medically related social, psychological, emotional, and spiritual support. Help participants and caregivers navigate healthcare, benefits, housing, transportation, social-service, and community-resource systems. Identify gaps in services and coordinate appropriate interventions. Maintain ongoing communication with participants, caregivers, service providers, and members of the IDT. Follow up on referrals and confirm that participants can access approved services. Coordinate support across the participant's