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Fallon Health FHW Social Worker - Growing Elder Service PACE program - 3 month position in Amherst, NY, New York


Fallon Health Vaccination Requirements:

To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022, all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

About Fallon Health Weinberg - PACE:

Fallon Health Weinberg-PACE is a long-term care program for older adults who need a nursing home level of care , but wish to stay living at home and in their community. We are a Program of All-inclusive Care for the Elderly (PACE), providing complete medical care and support services so you or your loved one can remain living safely at home . All care is coordinated and provided by an interdisciplinary team specializing in geriatric care, who work with participants and their caregivers to create an individualized care plan .


The Social Worker provides services to members as referred by Nurse Case Managers and/or Navigators. The Social Worker assesses member needs, services and resources to address social, health, or economic needs of FHW members. This position assists the Enrollee and/or family in utilizing FHW benefits and/or community resources; develops a plan to coordinate a continuum of care consistent with the Enrollee’s health care needs and goals; and is able to utilize knowledge of benefit plan design, eligibility and/or financing alternatives that are available within the community to ensure Enrollees’ needs are met. The Social Worker is able to identify services, care delivery settings, and funding arrangements and recommends alternatives where appropriate.

The Social worker is an active participant in the Members Primary Care Team (ICT) and will participate in the ICT providing input and guidance to resources, services, social dynamics and needs of assigned members.

The Social worker utilizes varied interviewing techniques including but not limited to motivational interviewing, and employs culturally sensitive strategies to engage and work with members. The Social worker may visit the members in the home and long-term care setting to assess needs and monitor progress towards patient agreed upon goals.


Primary job responsibilities:

The Social Worker collaborates with the Interdisciplinary Care Team. The Social Worker monitors the care and provides consistent feedback to the ICT on progress; works with community based groups to address service gaps; and serves as a liaison to social and health resources. The Social Worker is responsible for all activities related to:

  • Working directly with the ICT to assess the needs of Enrollees and assisting in the development of customized, proactive care plans resulting in the Enrollee attaining and/or maintaining an optimal functional status.

  • Ensuring timeliness in the coordination and receipt of community services in compliance with documented care plan goals and objectives.

  • Following Department and regulatory standards, seeks supplemental benefits and/or community services, as appropriate, to meet an Enrollee’s needs regarding: housing, food, clothing, transportation, financial assistance and other social supports.

  • Identifies, aligns, and utilizes health plan and community resources that impact high-risk/high cost care.

  • Creates contingency plans for each step of the process to anticipate treatment and service complications, while ensuring that the Member attains pre-determined outcomes.

  • Streamlines the focus of the Member’s healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care.

  • Works collaboratively and cohesively with all members of the Primary Care.

  • Utilizes a successful communication style and methods to engage Member’s in care management – does not ‘easily give up’ and works to engage Member’s as appropriate.

  • Identifies and shares best practices strategies with the team.

  • Supports department colleagues, covering and assuming changes in assignment as assigned by Supervisor/Designee.

  • Strictly observes HIPPA regulations and the FHW policies regarding confidentiality of member information.

  • Performs other responsibilities as assigned by the Supervisor/designee.



Graduate from an accredited school of social work – Master’s degree required, LMSW a plus


  • Valid and unrestricted license to practice social work in the state of New York;

  • Certification in Case Management desired, encouraged upon hire

  • reliable transportation required


  • A minimum of three to five years’ clinical experience as a Social worker with demonstrated experience working with the chronically ill, geriatric patients.

  • Experience in Home Health/community setting, working with Medicare/Medicaid preferred.

  • Experience working with patients in Long term care setting a plus.

  • Background with disabled or behavioral populations preferred.

  • Familiarity with provisions of governmental and accrediting agency health plan requirements.

  • Strong demonstrated knowledge of Medicaid requirements to include impoverishment, trusts, requirements of medicare advantage programs and Managed Long term care.

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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.

Location US-NY-Amherst, NY

Posted Date 4 weeks ago (6/6/2022 12:45 PM)

Job ID 6885

# Positions 1

Category Social Work