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Social Worker

A Socail Worker at Element Care in Lynn serves as a member of the PACE Interdisciplinary Team. Works under the direction of the Site Coordinator. Participates as a member of the PACE Interdisciplinary Team in the planning, implementation and evaluation of care plans that meet the objectives, standards and policies of the PACE model of care. Demonstrates proficiency in providing traditional social work services in a professional and respectful manner with the goal of assisting frail elders to remain living in the community for as long as they can do so safely.

Essential Functions: 

  • Attends daily team meetings and other team meetings, as needed, to share information and participate in developing participants' care plans.
  • Completes initial, periodic and annual psychosocial assessments for all assigned participants.
  • Assesses the psychosocial needs of the participant and provides therapeutic counseling, or refers the participant to an appropriate mental health provider, as indicated.
  • Facilitates hospital, rehabilitation and nursing home admissions and discharges as determined by the Interdisciplinary Team. 
  • Assists in the conversion of the participant from community to long-term care.
  • Communicates all participant related pertinent information with the Interdisciplinary Team in a timely fashion, and works with the Team to develop appropriate care plans. 
  • Insures that all interactions with participants and their families are conducted in a manner that adheres to the highest standards of care for all Element Care participants.
  • Arranges and facilitates family meetings, as needed. 
  • Assesses caregiver needs and takes a pro-active approach to implement supports that will prevent or address care giver burnout.
  • Maintains professional, accurate and timely social service documentation in the participants' medical records.

Additional Responsibilities:

  • Facilitates Participant Council Meetings.
  • Completes applications for eligibility of services (e.g. food stamps, SSI, housing, transportation, fuel assistance, etc.) as indicated.
  • Records monthly statistical information as required by Data PACE.
  • Participates in Quality Improvement projects and assessments, as needed.
  • Participates in Element Care Committees, as required.
  • Completes the required annual Health Stream trainings in a timely manner.
  • Adheres to all policies and procedures, and supports the Primary Vision Statement.
  • Adheres to the confidentiality policy of Element Care including HIPAA guidelines pertaining to the release of participant information. 
  • Flexible to perform other related duties, as is reasonable.


1. Required Degree - Master of Social Work
2. Current Social Work licensure in the Commonwealth of Massachusetts at the Masters level (L.I.C.S.W. or L.C.S.W.) preferred.
3. Maintain continuing education credits for re-licensure.
4. Current C. P. R. Certification

1. Minimum of 2 years of experience in Social Work providing traditional Clinical or Case Management services with a geriatric population.

1. Ability to be able to relate well to participants, to anticipate their needs and to encourage their independence. 
2. Ability to convey information clearly and succinctly with team members, to insure that relevant participant related information is available to the appropriate disciplines and departments.
3. Ability to be able to work well with others.

1. Ability to pay attention to detail, to be a self-starter, and to complete assignments on time with minimal direction. 
2. Ability to be able to quickly recognize situations/problems before they become acute, and to be able to implement effective solutions and understand consequences.