Join East Boston Neighborhood Health Center’s PACE program where the Social Work role is engaging with every day offering exciting new challenges. As part of a dynamic Interdisciplinary Team (IDT) in an innovative model of care, you will develop plans of care for participants who want to live safely in their communities. You will work with participants at the PACE Centers and in their homes addressing issues ranging from high risk mental health, end of life, medical decision making, caregiver support, and more. Responsibilities include conducting psychosocial assessments, formulating treatment plans, providing counseling, with opportunities for running groups and coordinating care with interdisciplinary team members to support participants achieving their goals. You must have an MSW and be passionate about serving adults 55+. Experience working with older adults preferred. Car required. Must possess or be working toward licensure as a LCSW or LICSW in MA. Bilingual (English/Spanish) is required for this role and language assessment will apply. Essential Duties and Responsibilities: Responsible for intake and enrollment, including ability to administer a complete psychosocial assessment and identify factors that impact upon the participant’s current level of functioning. Completes initial assessments and contributes to the plan of care by recognizing and articulating the way PACE and family can meet, maintain or enhance a potential participant’s level of functioning in the community. Coordinates, and demonstrates a leadership role in family meetings evidenced by the ability to restate important themes and articulate conclusions or next steps. Participates actively as part of an Interdisciplinary team. Sharing Initial and Bi-annual assessments. Writes and follows up on stated treatment interventions reflected in the IDT care plan. Develops and leads activities, which demonstrate an area of clinical expertise. This may include but not be limited to group counseling, resource management, psycho-therapy, end-of-life care, supervision of social work interns, or case presentation at the ethics committee. Demonstrates knowledge by participating and attending appropriate workshops and seminars Assists team in obtaining bed for participants needing long term or short term SNF placement. Coordinates admissions and discharges for participants in need of psychiatric hospitalization Qualifications and Requirements: LCSW or LICSW. 1 year experience in a social work capacity in a community setting preferred. Experience in working with the elderly, preferably in an interdisciplinary team setting. The ability and willingness to assist outside of traditional roles. You must have your own transportation for occasional home visits. Bilingual (English/Spanish) required.