Location: CHA East Cambridge Care Center 
Work Days: 8:00am - 4:30pm
Category: Human and Social Services
Department: CHA PACE  
Job Type: Full time  
Work Shift: Day 
Hours/Week: 40.00 
Union Name: Union of Social Workers

About CHA PACE

Cambridge Health Alliance's Program of All-Inclusive Care for the Elderly (PACE) is a nationally recognized model of care that serves adults aged 55 and older living with chronic medical and/or mental health challenges. 

At CHA PACE, our mission is to support our program participants in achieving the highest level of independence within their communities and preventing nursing home placement. Our high-functioning interdisciplinary team supports this goal by providing fully integrated medical and behavioral health services, community resources, and home-based care in a collaborative and supportive environment. 

Position Overview

The PACE Caseworker plays a vital role in supporting participants and families by coordinating services in alignment with the PACE model of care. Working closely with the interdisciplinary team (IDT), the Caseworker helps develop, implement, and monitor participant care and discharge plans that reflect individual goals and team recommendations. 

This position also serves as a navigator for new PACE enrollees and their families, helping them understand services, access concrete resources, and transition smoothly into the program. The Caseworker builds empathic, trusting relationships with participants, supports concrete service needs, and documents participant progress in the medical record.

Key Responsibilities

• Frame and implement interventions consistent with the PACE model of care and the participant’s individualized plan of care

• Act as a participant and family navigator, particularly for new enrollees

• Provide psychosocial casework, referrals, and concrete services for participants and families dealing with medical, psychiatric, and substance use challenges

• Translate materials when needed and assist in developing culturally sensitive, literacy-appropriate educational resources

• Develop and participate in forums and programs that provide community education on health screenings, benefits eligibility, and prevention services

• Collaborate closely with the interdisciplinary team, including social workers and team leaders, to provide outreach, education, and basic counseling services

• Coordinate with community agencies, caregivers, and benefits/entitlement offices to ensure access to community-based supports

• Complete documentation, forms, statistics, and medical record entries accurately and in a timely manner

• Participate in activities of the CHA Department of Social Work

• Perform additional duties as assigned by the supervising Social Worker

Qualifications

• BS in related health field or relevant experience in lieu of a degree

• Demonstrated experience working in multicultural and multidisciplinary settings required. Experience working with relevant community groups preferred

• 1 year experience working with the geriatric population preferred

• At least 2 years experience with Care Coordination, Discharge Planning, Utilization Review, or similar preferred

• Bicultural and/or bilingual in the specific cultural/language group of the population/community served preferred

• Reliable transportation for home visits

• Flexibility, initiative, creativity, and excellent organizational skills

Please note that the final offer may vary within the listed Pay Range, based on a candidate's experience, skills, qualifications, and internal equity considerations.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.