Senior Services Social Worker I

Job Description: Senior Services Social Worker I

Reports To: Senior Services

Director Supervises: No One

Status: Non-Exempt

Location: Access to Healthcare Network – Las Vegas

About Access to Healthcare Network (AHN)

Access to Healthcare Network (AHN) is a mission‑driven nonprofit dedicated to improving access to quality healthcare and supportive services. We foster a collaborative, respectful, and dynamic work environment where team members feel valued and supported. Joining AHN means contributing to meaningful work that positively impacts seniors, individuals with disabilities, and underserved community members.

JOB PURPOSE

The Senior Services Social Worker I supports older adults and individuals with disabilities in accessing services, resources, and supports that promote independence, community integration and quality of life. This position is primarily assigned to Money Follows the Person (MFP) Program where it serves individuals transitioning from institutional settings, including nursing facilities and other long-term care environments, into community-based living arrangements.

Working in partnership with healthcare providers, community organizations, and housing partners, this position provides person centered transition planning, care coordination, resource navigation and follow-up services to ensure participants achieve safe, successful, and sustainable community living. This position serves as a key member of the MFP team and is responsible for helping participants identify goals, access services and supports, overcome barriers to community reintegration, and maintain independence following discharge from institutional care.

KEY RESPONSIBILITIES

Transition Planning & Coordination

• Conduct comprehensive assessments to identify participant strengths, needs, preferences, and goals related to community living.


• Develop and implement person-centered transition plans in collaboration with participants, family members, facility staff, and community partners.


• Coordinate services necessary for community reintegration, including healthcare, behavioral health, transportation, nutrition, housing, and long-term support services.


• Facilitate communication among providers and stakeholders to ensure seamless transitions and continuity of care.


• Participate in interdisciplinary team meetings and case conferences as required.

Case Management & Support

• Maintain regular contact with participants before, during, and after transition to community living.


• Monitor participant progress and service delivery to ensure needs are being met.


• Identify and address barriers that may impact successful transition outcomes.


• Assist participants in obtaining benefits, services, and community resources.


• Provide education regarding available supports, rights, choices, and self-advocacy.

Resource Navigation & Community Partnerships

• Build and maintain relationships with nursing facilities, hospitals, housing agencies, social service organizations, and community providers.


• Connect participants to appropriate community resources and services.


• Collaborate with state and local partners to improve access to community-based services and supports.


• Participate in outreach, education, and networking activities that promote MFP services and objectives.

Documentation & Compliance

• Follow all MFP program requirements, policies, and procedures.


• Maintain accurate, timely, and complete participant records in accordance with program, agency, and regulatory requirements.


• Document assessments, service plans, referrals, participant contacts, and outcomes.


• Track participant progress and required program data for reporting purposes.


• Ensure compliance with all applicable confidentiality requirements, including HIPAA.

Outreach & Service Delivery

• Provide case management services by phone, email, or in-person at approved locations.


• Conduct home visits and offsite outreach as needed to meet consumer needs.


• Participate in outreach, marketing, and public education activities, including community events.

Professional Responsibilities

• Maintain working knowledge of AHN programs, systems, and required databases.


• Communicate effectively with supervisors and internal departments.


• Attend staff meetings and supervision sessions.


• Adapt to changing priorities and perform other duties as assigned.

Minimum Qualifications

• Bachelor's degree in social work, Human Services, Psychology, Gerontology, Public Health, or a related field required.

Experience

• Minimum of two years of experience in case management, care coordination, discharge planning, social services, aging services, disability services, healthcare, behavioral health, or a related field.


• Experience working with older adults, individuals with disabilities, or persons requiring long-term services and supports preferred.

ADDITIONAL REQUIREMENTS

• Spanish – English Bilingual preferred.


• Must obtain Medicare Assistance Program Level II Certification within 2 months of hire.


• Valid Nevada Driver's License required with an acceptable five-year driving record that meets AHN insurance requirements.


• Occasional use of personal vehicle for business related travel may be required, with reimbursement provided according to organizational policy.


• Flexibility to accommodate department-determined work schedules, which may change based on operational needs.


• Must pass a State of Nevada screening check and adhere to HIPAA regulations.

WORK ENVIRONMENT

• The noise level in the work environment is usually moderate, and the employee usually works in a climate-controlled office environment.


• Ability to travel and drive for extended periods (up to four hours at a time).


• Ability to operate an AHN company vehicle as needed.


• Be able to sit at a computer for 6 – 8 hours per day.


• Be able to stand between 3 – 6 hours per day.


• Be able to withstand hand/wrist deviation and repetition.


• Must be able to lift, carry up to 30 pounds with a fair consistency.

FUNDING CLAUSE

This position is funded through external grant sources. Continued employment is contingent upon the ongoing availability of this funding. If funding is reduced or discontinued, the position may be changed or eliminated.

As an equal opportunity employer, we are committed to identifying and developing the skills and leadership of people from diverse backgrounds. We encourage all qualified candidates to apply.

Benefits:

• Medical Insurance & Vision provided at no cost to the Employee


• Health Savings Account HDHP (HSA) includes employer matching $35.00 per month


• Dependent Care Flexible Savings Account (FSA)


• Low-cost health insurance options for your dependents


• Dental insurance


• Free Life Insurance and Long-Term Disability


• Voluntary Ancillary Benefits


• 4 Weeks Paid Time off in your first year


• WFH Options


• 14 Holidays


• Bereavement Leave


• 4 weeks Paid parental leave


• Tuition Assistance and more!

Required to pass a background check through the State of Nevada