Social Worker PACE (Full Time) – San Diego

St. Paul's Senior Services - Careers

Location: San Diego

St. Paul’s is the leading provider of caring senior services since 1960. We are centrally located in the beautiful community of Bankers Hill, near downtown San Diego. St. Paul’s strives to be the most outstanding and innovative senior home and service provider in California. We are dedicated to serving the physical, spiritual and social needs of the elderly and community, fostering a culture of diversity and inclusion within the highest quality facilities, health care and programs consistent with affordable costs.


Under the supervision of the Social Work Supervisor, plans, organizes, and implements social work services to St. Paul’s PACE participants and families. Responsibilities include but are not limited to: assessment, care planning, treatment, teaching and counseling to participant, caregiver or other appropriate representatives. The Social Worker Interventions could include: individual participant contact; appropriate collateral contact; participant and family education, assessment, and counseling; provision of resources; addressing mental health needs as they arise; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The Social Worker is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.


Management of social work department, supervision of social work department staff, completion of QAPI projects, assessment, treatment, teaching and counseling to participant, caregiver or other appropriate representatives. The Social Worker Interventions could include, individual participant contacts; appropriate collateral contact; participant and family education, assessment, and counseling; provision of resources; addressing mental health needs as they arise; ongoing case management; advocacy to ensure participant and caregiver needs are met and addressed; and disenrollment procedures. The Social Worker is the liaison between the interdisciplinary team, caregiver representatives, and community agencies.

Education:   Master’s Degree from an accredited school of Social Work required. Waiver from CMS permitting MSW-level responsibilities for a non-MSW Social Work employee.

Experience: A minimum of one year’s experience working with a frail or elderly population required. Experience working on a multidisciplinary team in a hospital, nursing home or community-based setting preferable. Mental health and substance abuse experience preferred. Shall have either training or related experience in the job assigned.


    • Experience with frail/chronically ill elderly people.
    • Experience with individuals who have mental health and/or substance abuse issues.
    • Ability to provide psychosocial assessment and individual, family and group counseling.
    • Effective verbal/written communication skills with the ability to maintain accurate records and to prepare clear and concise reports, correspondence and other written materials.
    • Good public speaking skills with all size groups.
    • Ability to communicate clearly and effectively verbally and written.
    • Current California Drivers License, proof of auto insurance and consistent and reliable usage of a motor vehicle.


Physical Requirements: Shall be in good mental and physical health, and capable of performing assigned tasks. Requires frequent standing and walking, occasionally pushing, pulling, stooping, and kneeling. Requires manual and finger dexterity and eye-hand coordination; the ability to use department equipment; and the ability to lift/carry up to 50 pounds using appropriate body mechanics. Must be able to operate a motor vehicle in order to perform home visits.

Visual, Hearing & Communication Requirements: Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Must be able to document care provided in participant records. Must be able to communicate verbally with participants, family and team.

Pressure Factor: Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuating indoor temperatures. Required to meet scheduled appointments while dealing with frail and confused participants. Subject to participants that may have the potential for verbal or physical aggression as well as difficult family dynamics, including caregivers under stress.

Environmental Conditions: May be exposed to a risk with contact of toxic substances, bodily fluids, communicable diseases and any other conditions common in a healthcare environment. Subject to unpleasant odors and living conditions in participant homes.


    • Shall attend in-service education program, including orientation, skill training and continuing education.
    • Is required to receive training in first aid and CPR within the first six months of employment and to maintain certification in first aid and CPR throughout period of employment.
    • Performs in person initial assessments for enrollment of potential St. Paul’s PACE participants to obtain a complete psycho-social history, which may include descriptions of cognitive status, social supports, family dynamics, mental health and substance dependency, and other current issues and needs. Coordinates with the interdisciplinary team to develop a comprehensive care plan for each participant.
    • Assumption of responsibility for implementation and coordination of the admission and/or discharge plan.
    • Conducts in person reassessments of enrolled participants every six months and as needed.
    • Functions as a member of the interdisciplinary team. Maintains regular attendance at and participates in interdisciplinary team meetings; communicates participant changes, collaborates on care planning decisions and coordination for 24 hour care delivery.
    • Acts as liaison with participant, caregivers, and community agencies regarding orientation to and ongoing relations with interdisciplinary team, day center, and other St. Paul’s PACE staff.
    • On an annual basis (during annual or semiannual reassessment) presents the written participant rights documentation to assigned participants and or caregiver. In the event the participant is unable to understand the information, the social worker will ensure the caregiver or representative understands the participant rights. If there is a language barrier the Social Worker will provide the appropriate interpreter.
    • In the event of disenrollment of the participant from St. Paul’s PACE, the social worker will act to coordinate the transitional care necessary to ensure continuation of care during and after termination. They shall assist participants to obtain reinstatement of conventional Medicare and Medi-cal benefits, as well as VA benefits when applicable; will transition participants’ care to other providers, make all appropriate referrals, and make the participants’ medical records available to new providers with appropriate participant approvals.
    • Provides ongoing support, counsel, and education to participants and family/significant others regarding a variety of issues, including but not limited to: the aging process, dementia, grief and loss, end of life, disease processes, difficult family dynamics and changing roles, PACE model and PACE health services, mental health education and treatment, and substance abuse education and treatment.
    • Provides opportunity for problem oriented discussion groups among participants.
    • Works to access and maintain participant housing through intervention with participant, caregivers, and housing. Will proactively work to partner with participant and/or caregivers to maintain appropriate housing and assist participant to function at most independent community level possible.
    • Presents requests to interdisciplinary team for and coordinates admission/discharge to contracted facilities for temporary respites and permanent placement.
    • Performs home visits quarterly or as needed to assess living environment and support system.
    • Acts as facilitator for meetings with participant, family, caregivers, and community agencies to clarify, or problem solve issues regarding the Plan of Care. Mediates discussions between all parties.
    • Provides referrals to and assessments with contracted Personal Care agencies, Board & Care Homes, Supportive Housing, and Assisted Living residences. This may involve completing applications, obtaining medical records, accompanying participants to interviews, assessments, and tours if participant has no other support systems.
    • Coordinates hospital discharges in conjunction with interdisciplinary team and communication with attending physician. Communicates with family or caregivers frequently and as needed to update.
    • If end of life care is appropriate, actively provides emotional support, grief counseling, education, and funeral/financial planning referral. Facilitates hospice or nursing home placement as needed.
    • Initiates referrals to external resources with community agencies such as VA, original referral agencies, Adult Protective Services, Housing Authority, or public utility companies. Advocates with these entities for purposes of maintaining community stability.
    • Assists participants and caregivers to complete MDPOA, Proxy, and DNR directives as needed.
    • Attends and actively participates in a variety of organizational meetings related to participant care or daily operations, including but not limited to: Morning Meeting, various in-services and community agency meetings, in-service education, and other supportive housing general meetings.
    • Acts as a resource for education and training to other team members regarding topics such as dementia, difficult behaviors, mental health issues, and difficult personalities.
    • Completes and ensures completion of documentation of clinical service in participants’ medical records including initial assessments, reassessments; change of status; temporary or permanent placements; hospital admissions and discharges; home and nursing home visits; and other significant events according to St. Paul’s PACE documentation requirements. Maintains signed progress records in the participant health records at least minimally.
    • Assists participants with SSI,SSDI, General Relief, Food Stamps, VA benefits, Medi-cal, and other benefits application processes as needed.
    • Assists participants and caregivers in filing grievances and appeals.
    • Assists participants and family in coordination with Enrollment Specialist to keep resources within guidelines for Medi-cal eligibility.
    • Assists Enrollment Specialist with referrals for referred individuals not appropriate for PACE or other contracted supportive housing programs.
    • Coordinates care for participants residing in skilled nursing facilities by attending SNF care conferences and maintaining at least monthly contact with participants and SNF social services staff.
    • Follows all St. Paul’s PACE Policies and Procedures and OSHA safety guidelines.
    • Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants, and families.
    • Practices Universal precautions following all appropriate Infection Control procedures.
    • Maintains safe working environment. Follows St. Paul’s PACE Care Safety Policies and Procedures.
    • Participates in and supports Quality Improvement initiatives.
    • Participates in continuing education classes and any required staff and training meetings. Maintains professional affiliations and any required certifications.
    • Performs other duties as required.

REPORTS TO: Social Work Supervisor


If you prefer to fax your application and resume you may fax it to 619.239.1256. We also accept applications in person at 328 Maple Street, San Diego, CA 92103. Come to the 2nd floor and let the receptionist know you would like to complete an application.

To learn more about St. Paul’s Senior Services, please visit


St. Paul’s Senior Services is an Equal Opportunity Employer