Social Worker I

Job ID
Social Services


Responsible for AltaMed PACE participants assigned to the team. This position works closely with providers and nurses to coordinate services and advocate for participants. Responsibilities include, but are not limited to; quarterly notes, conducting family conferences, assisting with community referrals, regular contacts with participants, and incident reporting.


  1. Responsible for quarterly notes and developing care plans for assigned team/participants and completes within monthly timeframe set by state guidelines.
  2. Interview and screen participant’s family members and caregivers to indentify additional need for psychotherapeutic intervention and inform immediate supervisor.
  3. Provide information and referral to participants and family and assist with coordination of services through public, private and social services agencies.
  4. Act as a liaison with participant’s family, caregiver and for with other community agencies providing services to participants.
  5. Document all PACE participants and family contacts in accordance with PACE documentation guidelines.
  6. Works with PACE Care Coordination Team (RN, OT, PT, Activities) by taking lead in investigating non-clinical psycho-social problems as identified by the PACE inter-disciplinary team and documents in PACE Nextgen & PACE support systems.
  7. Coordinates family conferences and attends team meetings with provider and R.N.
  8. Perform participant psychosocial tasks as assigned by Social Worker Supervisor and PACE Administration.
  9. Participates in daily PACE Inter Disciplinary Team meetings and other mandatory meetings.
  10. Mandatory contacts with participants and develops and conducts specialized therapeutic groups for PACE participants at least one time a month.
  11. Provide home visits if unable to contact by phone and provide feedback to team and supervisor.
  12. Support and maintain a caseload as mandated by Title XXII requirements.
  13. Perform other related duties as assigned.


  1. PACE requirement: Bachelors’ degree in Social Work from an accredited university and one year experience in case management/social advocacy with geriatric population.
  2. PACE: CPR/First Aid certificate required.
  3. PACE: Bilingual English/Spanish, English/Tagalog or another second language strongly preferred.


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