Medical Social Worker

$45.17 - $60.22 hourly
  • On Lok
  • 1333 Bush Street, San Francisco, CA, USA
  • Dec 28, 2023
Full time Health Care

Job Description


We are a non-profit committed to our participants.

Dedicated to The Care of Elders:

PACE (Program of All-Inclusive Care for the Elderly) was developed to answer the many problems around caring for frail seniors. The PACE model is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in their community whenever possible.

Seniors, their family members, and caregivers face many issues, including transportation to appointments, management of medications, coordination of medical care from different specialists, lack of social interaction, and ability to stay alone at home. On Lok PACE participants receive in home care services and transportation to a On Lok PACE center for primary medical care, social and recreational activities, and other senior care services.

We understand the importance of a system that works together. Your expertise, drive and passion can help us carry out our mission to improve lives and advance healthcare.

Join our team of leaders to begin a rewarding career!


The Social Worker provides direct case management services to On Lok participants. The primary role of the MSW is to assist participants and their family/caregivers to cope with the social and emotional issues and practical arrangements related to maintaining their independence. With support from the Social Work Lead, the MSW serves as an integral member of the Interdisciplinary team (IDT) providing assessments, coordination, treatment planning, information and referral to community resources and other social work services to meet the complex needs of participants and their families.


Clinical Practices and Case Management

  1. Utilize independent judgement and discretion to provide case management to a panel of participants.
  2. Conduct initial and routine psychosocial assessments on new and existing participants in order to develop, implement and update individualized care plans and interventions.
  3. Partner with caregivers and support system to develop care plan and deliver services.
  4. Identify risks and other psychosocial problems.
  5. Identify service needs of each participant; advocate, refer, coordinate and follow up in a timely fashion.
  6. Provide individual counseling.
  7. Facilitate family conferences.
  8. Reach out to the larger community to meet participants' specific needs.
  9. Assess needs and complete discharge planning when a participant dis-enrolls from On Lok.
  10. Facilitate participant and/or caregiver groups and participate in special events such as weekend caregiver workshops.

Interdisciplinary Team Member Roles and Responsibilities

  1. Act as the main liaison between participants, caregivers, the team, and the community.
  2. Work with relevant departments such as Health Plan and other community agencies (e.g. RCFE, NF, DAAS)
  3. Adhere to all ethical and legal standards of social work practices.
  4. Comply with all On Lok policies & procedures including but not limited to PACE, safety, and confidentiality requirements.
  5. Fulfill all documentation requirements in a timely and accurate manner.
  6. Actively participate in team meetings, advocate for the needs of participants and their caregivers, compromise differences among team members, support and carry out team plans.
  7. Incorporate the Healthcare Hospitality G.R.E.A.T. Practices for 5-Star service.
  8. Assist in the continuous quality improvement of social work services and efficiency of systems.
  9. All other reasonably related duties as assigned.

QUALIFICATIONS (knowledge, skills, abilities):

  1. Graduate of an accredited college with a Master's of Social Work degree.
  2. Minimum one-year experience with the frail or elderly.
  3. Experience or ability in working with a diverse population.
  4. Experience working within the framework of an interdisciplinary team.
  5. Good interpersonal skills including ability to work cooperatively on an interdisciplinary team.
  6. Highly organized, able to prioritize tasks and conduct thorough follow-up.
  7. Excellent written and verbal communication skills.
  8. Computer literate and basic knowledge of Microsoft Office.
  9. Bilingual ability may be required for specific assignments.
  10. Experience with electronic health record system (preferred).
  11. Minimum one-year post MSW experience (preferred).
  12. Minimum one-year case management experience (preferred).
  13. Minimum one-year health care related experience (preferred).


  1. Required to work in the field such as participant's home and other community settings.
  2. May be required to travel to other locations for meetings or trainings.
  3. Required to work in a fast pace, highly distractible setting.


  1. While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee occasionally is required to climb and stoop, kneel, crouch, or crawl.
  2. Specific vision abilities required by this job include close vision, and ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  3. The employee must occasionally lift and/or move up to 25 pounds.

The above statements are intended to describe the general nature of work performed. They are not considered as an exhaustive list of all job tasks performed. On Lok reserves the right to change job descriptions, work hours or work sites as required by the program.

On Lok's Employee Benefits include (eligible for any position for 20 hr/wk or more):

  • Medical, Dental, and Vision coverage
  • Retirement Savings Plan 403(b) and Term Life/AD&D Insurance
  • Flexible Spending Account, Commuter Checks, MLA scholarships, Employee Assistance Program (EAP)
  • Pet Insurance and additional discounts
  • Holidays (10 per year), vacation time, sick leave, and long-term disability insurance

Your final compensation offer will be determined based on factors such as skills, experience, education, and licenses/certifications. The pay range is expressed as an hourly rate regardless of FLSA status. Exempt positions are paid salaried and are not subject to overtime.

Pursuant to the San Francisco Fair Chance Ordinance, and state and federal laws (including federal PACE requirements at 42 CFR 460.64(a); 460.68(a), we will consider for employment qualified applicants with arrest and conviction records.

On Lok is an equal opportunity employer committed to a diverse and inclusive workforce. All applicants will receive consideration for employment without regard to sex (including pregnancy), race, religion, color, gender, gender identity, gender expression, sexual orientation, national origin, ancestry, disability, medical condition, genetic information, marital status, age, military or veteran status, or any other legally protected status.

If you require reasonable accommodation to participate in the job application or interview process, to perform essential job functions and/or to receive other terms, privileges or benefits of employment please contact Talent (