PACE Social Worker Assistant

For more than 55 years, Family Health Centers of San Diego’s (FHCSD) mission has been to provide caring, affordable, high-quality health care and supportive services to everyone, with a special commitment to uninsured, low-income and medically underserved persons.

FHCSD is one of the top 10 largest federally qualified health centers (FQHCs) in the country. We operate more than 90 sites across San Diego County, including 29 primary care clinics, 23 behavioral health facilities, 10 physical rehabilitation clinics, nine dental clinics, five vision clinics, four outpatient substance use treatment programs, three mobile medical units, two mobile counseling centers, two urgent care centers, and a pharmacy.

Our staff provides care to over 227,000 patients each year, of whom 91% are low-income and 29% are uninsured. FHCSD provides care to all. Services include, but are not limited to adult care, chronic disease management, pediatrics, comprehensive women’s care including obstetrics, dental, vision, case management, physical rehabilitation, speech therapy for children, vaccinations, infectious diseases, behavioral health, substance use counseling and a host of specialty services including cardiology, podiatry, endocrinology, dermatology, among others.  FHCSD also offers supportive services to those who are unsheltered and in need of intensive case management.   

The breadth of our clinic locations, services and programs has grown over the last five decades, making us the largest community clinic provider of health care to the uninsured in the county and one of the top 10 largest community clinic organizations in the nation. We are also the largest health care safety-net provider, largest school-based health care provider and the largest mental health provider in the San Diego region.

General Job Description:

Under the supervision of the Social Worker and PACE leadership, provides support services to assist participants and caregivers in navigating community resources, social service programs, and care coordination needs. Assists with case management activities, documentation, participant follow-up, and coordination of services to support participants in remaining safely in the community.

Job Roles

• Assist participants with applications and access to community resources and social service programs, including Medi-Cal, CalFresh, housing resources, transportation services, financial assistance programs, and other supportive services.
• Assist Social Workers with case management activities and follow-up for participants and caregivers.
• Serve as a liaison between participants, families, caregivers, community agencies, hospitals, skilled nursing facilities, assisted living facilities, and the interdisciplinary team.
• Support transitions of care, including hospital admissions, hospital discharges, skilled nursing facility admissions and discharges, and community placements.
• Assist with scheduling and coordinating family meetings, care conferences, and participant-related meetings.
• Provide telephone support and participant follow-up as directed by the Social Worker.
• Conduct home visits and community visits as assigned and under the direction of the Social Worker.
• Assist participants with completion of forms, applications, benefit renewals, and document management activities.
• Coordinate referrals to community agencies and supportive services.
• Maintain current case management records and documentation in accordance with organizational standards and regulatory requirements.
• Assist with collection and organization of participant information for interdisciplinary care planning activities.
• Support participant enrollment, disenrollment, transfers, and continuity of care processes.
• Communicate participant concerns, psychosocial needs, and significant changes to the Social Worker and interdisciplinary team in a timely manner.
• Participate in interdisciplinary team meetings, care planning discussions, and departmental meetings as assigned.
• Assist with participant engagement activities, support groups, educational programs, recreational activities, and community outings.
• Maintain confidentiality and comply with HIPAA, CMS, DHCS, and organizational requirements.
• Promote excellent customer service and positive participant experiences consistent with organizational values and AIDET principles.
• Perform other duties as assigned.

Education/Certifications/Licenses/Registrations

• Bachelor’s degree in social work or related field preferred
• Current American Heart Association healthcare provider CPR (BLS), or Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advance Resuscitation Training required.
• Traveling between sites and other locations is required as an essential function of the job. Must have a car, a valid California driver’s license, and proof of minimum levels of car insurance as required under California law, although limits of $100,000 are recommended. An acceptable driving record is also required. California law requires all drivers to obtain a valid California driver’s license within ten days of establishing residency. Mileage and other reimbursement governed by policy.

Experience/Specialized skills (including Language)

• Minimum 1 year of experience in case management, care coordination, social services, community outreach, healthcare, behavioral health, senior services, or a related field preferred.
• Experience working with frail elders, older adults, individuals with disabilities, or vulnerable populations preferred.
• Knowledge of community resources, health care systems, and social service programs within San Diego County preferred.
• Ability to establish and maintain effective working relationships with participants, families, caregivers, community agencies, and interdisciplinary team members.
• Excellent interpersonal, customer service, and communication skills.
• Ability to organize multiple tasks and meet deadlines in a fast-paced environment.
• Ability to maintain participant confidentiality and exercise sound judgment.
• Demonstrated ability to work effectively with culturally diverse populations.
• Strong problem-solving, organizational, and follow-up skills.
• Bilingual English/Spanish preferred.
• Basic computer literacy including electronic health records, Microsoft Office applications, email systems, and documentation systems.

We are excited to share that the salary range for this position is:

Information on our extensive benefits package can be found here: FHCSD Wellness – Employee Hub (gobenefits.net)

FHCSD provides Equal Employment Opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, transfer, leave of absence, compensation, and training.