About us:

Fallon Health is a company that cares. We prioritize our members--always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, we deliver equitable, high-quality coordinated care and are continually rated among the nation’s top health plans for member experience, service, and clinical quality.

Fallon Health’s Summit ElderCare® is a Program of All-Inclusive Care for the Elderly–PACE for short. PACE, an alternative to nursing home care, is a program that helps people 55 and older continue living safely at home. At Fallon Health, we believe our individual differences, life experiences, knowledge, self-expression and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status and other characteristics that make people unique. 

Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE— in the region. 

Brief summary of purpose: 

Functions as a member of the PACE Interdisciplinary Team and provides social work services and support to participants, families, and other caregivers.  Provides direction to bachelor’s level social workers as assigned by Social Work Manager.

Primary Job Responsbilities: 

• Participates in the intake and evaluation process by conducting the initial social work assessment, administering MSQs, developing an intake summary and presenting the social work perspective to the Interdisciplinary Team.
• Assures that participants rights are reviewed during the intake process.
• Conducts reassessments at least semiannually and whenever there is a change in participant status or the participant /caregiver requests it.
• Develops and implements a social service plan of care for each participant and updates it based on the results of reassessments or on-going changes in status.
• Responsible for the maintenance of appropriate records and documentation in the medical record including at least the initial assessment, quarterly progress notes, significant changes and all participant-related interactions.
• Participates as a member of the Interdisciplinary Team at daily team meetings and care planning meetings.
• Assists team members to understand the social, emotional, cultural and psychosocial aspecst of participants’ situations.
• Acts as an advocate and liaison when counseling services are needed.
• Completes documentation and record-keeping related to disenrollment’s, deaths and permanent placement; distributes relevant notifications.
• Participates in the development, promotion and implementation of caregiver support groups or programs; leads or co-leads groups as necessary.
• Assists in managing referral telephone calls as needed.
• Implements program policies and procedures as directed. 
• Assists in the conversion of participants from community based Medicaid to long-term care Medicaid when necessary. Works collaboratively with the Operations Support Representative to assure appropriate access to Medicaid benefits.    
• Pursues relevant professional development. Attends appropriate workshops and in-service activities to maintain current professional status.
• Consistently follows the Social Work Code of Ethics.
• Performs all duties in accordance with FCHP and Summit ElderCare policies and procedures.

Education: Master’s degree in social work

Licenses/Certification: Valid and unrestricted license to practice social work from the Board of Registration of Social Work of the Commonwealth of Massachusetts and reliable transportation required 

Experience: At least two years experience in a Social Work capacity, preferably in a community setting, with a minimum of one year experience working with a frail or elderly population. Generally, establishes own work plan and priorities, using and/or modifying established procedures, to assure timely completion of assigned work in conformance with program policies and standards; problems lacking in clear precedent are reviewed with Manager prior to acting.

Fallon Health 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, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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