Imagine a center where our seniors can receive transformative health care that will allow them to age at home and in their communities.
At Asian Health Services, we recognize that so many of our elderly patients continue to struggle to get the care they need because of challenges that go beyond the walls of the clinic.
To address these gaps, we’ve found a solution and model of care that integrates the quality care our elders receive at our health center with the most comprehensive support system, like transportation, culturally-inclusive meals, and social activities, our elders deserve.
We are building a Program of All-Inclusive Care for the Elderly (PACE) to bring life-changing, culturally competent care to low-income seniors—supporting them as they age safely and with dignity, right in their communities. Based on the PACE model, SpringLight Health will offer coordinated medical care, transportation, meals, social activities, medication management, and caregiver support—all tailored to each individual’s needs.
Learn more by visiting our website here.
Essential Job Functions
- Lead and participate in IDT assessments, care planning, and reassessments for new and existing PACE participants.
- Provide oversight and accountability for the delivery of medical social services, care management, counseling, psychosocial support, referrals, and participant advocacy.
- Supervise, mentor, coach, and evaluate Geriatric Services Specialists; oversee staffing, scheduling, performance, and team accountability.
- Partner with the IDT to develop and implement care plans that address participants’ medical, physical, social, emotional, psychological, and spiritual needs.
- Monitor participant changes and ensure timely communication with the IDT regarding health, psychosocial status, care needs, and required reassessments.
- Maintain accurate, timely social work documentation in the PACE EHR in accordance with federal PACE regulations, organizational policy, and documentation standards.
- Maintain signed progress records in the participant’s electronic health record at least quarterly.
- Coordinate 24-hour care delivery, discharge planning, home visits, hospital visits, skilled nursing facility visits, and follow-up services as needed.
- Serve as a liaison among participants, families, caregivers, community agencies, facilities, and service providers to promote continuity of care.
- Provide education and support to participants, caregivers, and staff regarding aging, dementia management, grief and loss, end-of-life considerations, disease processes, family dynamics, psychosocial needs, and the PACE service delivery model.
- Advise PACE staff on social, emotional, cultural, and community-resource factors that may affect access to care and participant outcomes.
- Maintain knowledge of Medicaid financial eligibility criteria, participant liability/share of cost, and applicable state nursing home Level of Care requirements.
- Support the PACE Quality Improvement program and participate in QI activities, audits, process improvements, and staff training as assigned.
- Ability to make home visits as appropriate and assigned.
- Perform other related duties and projects as assigned.
Minimum Requirements
- Master’s degree in Social Work from an accredited college or university.
- Minimum two (2) years of health-related experience.
- Leadership and/or management experience.
- Minimum one (1) year of experience working with a frail or elderly population; in the absence of such experience, must complete appropriate PACE training before providing direct participant care.
- Bilingual ability (Cantonese and/or Mandarin) and experience providing culturally and linguistically appropriate services.
- Demonstrated social work competencies, leadership skills, sound judgment, and ability to guide staff in a team-based care environment.
- Strong knowledge of community resources, care coordination, psychosocial assessment, documentation standards, and participant/caregiver support.
- Ability to provide respectful, participant-centered service to older adults, including those experiencing cognitive decline, physical frailty, grief, loss, or complex family dynamics.
- Must be medically cleared for communicable diseases and have required immunizations and vaccines before engaging in participant care.
- Must not have been convicted of criminal offenses involving Medicaid, Medicare, other health insurance or health care programs, or social services programs under Title XX of the Act.
- Must not have been convicted of criminal offenses related to physical, sexual, drug, or alcohol abuse.
- Must not be excluded from participation in Medicare or Medicaid programs.
Benefits That Support You
We're committed to supporting our team's well-being. Our comprehensive benefits package includes:
Health & Wellness
- 100% employer-paid medical, dental & vision coverage
- Acupuncture & chiropractic coverage
Time Off
- 12 vacation days
- 12 sick days
- 12 paid holidays + 3 floating holidays (additional flexible days you can use anytime)
Financial & Retirement
- 403(b) with 3% employer contribution + up to 2% match
- Flexible Spending Account (FSA) & Dependent Care Assistance
Additional Support
- Commuter benefits
- Long-Term Disability Insurance
Skills Required
- Master's degree in Social Work from an accredited college or university
- Minimum two years of health-related experience
- Leadership and/or management experience
- Minimum one year of experience working with a frail or elderly population, or completion of appropriate PACE training before direct participant care
- Bilingual ability in Cantonese and/or Mandarin
- Experience providing culturally and linguistically appropriate services
- Social work competencies, leadership skills, sound judgment, and ability to guide staff in a team-based care environment
- Knowledge of community resources, care coordination, psychosocial assessment, documentation standards, and participant/caregiver support
- Ability to provide respectful, participant-centered service to older adults experiencing cognitive decline, physical frailty, grief, loss, or complex family dynamics
- Medical clearance for communicable diseases and required immunizations and vaccines before participant care
- No disqualifying convictions involving Medicaid, Medicare, health insurance, healthcare, or social services programs
- No convictions related to physical, sexual, drug, or alcohol abuse
- Not excluded from participation in Medicare or Medicaid programs
What We Do
Asian Health Services is a non-profit community health center founded in 1974, serving over 50,000 patients in Alameda County. It provides comprehensive medical, dental, and behavioral health services using a 'whole patient health' approach. Dedicated to underserved Asian and Pacific Islander communities, the organization integrates clinical care with advocacy, health education, and social support, delivering services in English and at least 14 Asian languages.
