Bienvivir All-Inclusive Senior Health·El Paso, Texas
The Social Worker provides case management, advocacy, and social services to frail seniors and their families within the PACE program. Responsibilities include conducting home safety screens, managing intake processes, and collaborating with an interdisciplinary team to ensure quality of life.
Bienvivir All-Inclusive Senior Health (“Bienvivir”) is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors. Since 1987, Bienvivir has served the frail seniors of El Paso, Texas through the provision of the Program of All-Inclusive Care for the Elderly (“PACE”).
PACE is a unique managed care benefit for frail seniors (referred to as participants) age 55 and older who are certified by the state as needing nursing home level care and who reside in a PACE service area. PACE programs coordinate and provide comprehensive medical and support services so that participants can remain independent and stay in their homes for as long as safely possible.
Benefits: for Full and Part-time employees who work 30 or more hours per week:
We pay 100% of the MEDICAL monthly premiums for Employee Only coverage.
We pay 100% of the DENTAL monthly premiums for Employee Only coverage.
We provide an affordable VISION monthly premium for Employee + Family coverage.
We pay 100% of BASIC LIFE for a benefit amount of $10,000.
We offer safe harbor matching contributions for the 403(B) RETIREMENT SAVINGS account.
We offer up to fifteen (15) days of PAID TIME OFF based on paid hours per pay period.
We offer eleven (11) company-observed PAID HOLIDAYS.
We offer education and TUITION REIMBURSEMENT.
We offer MILEAGE REIMBURSEMENT.
Under the supervision of the Social Work Manager, the Bachelor Social Worker (BSW) is responsible for providing outreach, social services, advocacy, and case management to participants enrolled in the program and their families. BSW will provide support with generalist Social Work areas of operation. It is the responsibility of the Social Worker to ensure that the cultural/ethical considerations of participants are addressed in long-term care programming planning and treatment.
Case Management: 1. Provides case management services to Bienvivir participants. 2. Completes home safety screen as per fall policy if no home health services are in place. 3. Serves as a liaison with the participant’s family via home visits, family conferences, and telephone contacts, utilizing the appropriate approach to keep all parties informed. 4. Assists Master Social Worker (MSW) as needed to complete placement cost contract and submit for approval. 5. Completes medical alert referrals when approved by the Interdisciplinary Team (IDT). 6. Completes disenrollment documents (death and non-death). 7. Completes MSUR Service Delivery Day Unit form on a timely basis as needed. 8. Assists participants with reports that are required on an annual basis (i.e., Medicaid renewals, Surveys, etc.) 9. Refers participants and family members to community resources as needed to improve quality of life. 10. Attends daily IDT meetings, care plan meetings, Social Work Department meetings, and CEO bi-weekly meetings via ZOOM. 11. The Social Worker is a member of the Emergency Preparedness Team and will be available as indicated by the Emergency Plan 12. The Social Worker will provide ongoing communication to the participant/decision-maker regarding Participant Rights, Grievance and Appeals Process, and Care Planning. Behavioral Health: 13. Provides support to MSW assistance with completing Mini-Mental State Exam (MMSE) as scheduled. 14. Alert the MSW of any concerns voiced by visitors/participants related to Behavioral Health.
15. Establishes and maintains a positive relationship with BSHS Contracted Assisted Living/Foster Homes/ Nursing Home Facilities in order to ensure that when participants need placement or respite, their needs will be met appropriately and on a timely basis. 16. Serves as a liaison and advocate for participants and their families. With agencies such as Social Security, Health and Human Services Commission, the Housing Authority, Adult Protective Services, Probate Court, etc. 17. Assists in facilitating staff in-services by contacting outside presenters who have the expertise in providing services to the elderly.
18. Works in conjunction with the Intake Team (Customer Service Representatives, Intake Coordinators, Intake Nurse, Intake Manager, Physician and Medicaid Eligibility workers) during the enrollment process to initiate and process both financial and medical applications for all potential participants. 19. In conjunction with the Intake Team, schedules and completes MMSE, Health Care Wishes, and Enrollment Packet explanations for all applicants. Once a visitor is enrolled with Bienvivir, the Social Worker will transition each case to the Center-assigned Social Worker. 20. Reviews and completes the Enrollment Contract ‐ upon notification by the State of Texas that a Visitor has met all State requirements and is approved for Bienvivir services. 21. Serves as a liaison with the Visitor, their family, and/or caregivers via home visits, family conferences, and telephone contact and communicates appropriate information as needed. 22. May provide social services to all Visitors to include community-based referrals for outreach crisis counseling and intervention and advocacy and case management. 23. Provides education to Visitor and their family and/or caregivers regarding Advanced Directives, Medical Power of Attorney, and Guardianship. May initiate and complete Advanced Directives, Medical Power of Attorney, and Guardianship as needed. 24. Collaborates with Enrollment Team Physician and Nurse and refers Visitors and or family/caregivers to placement options as appropriate. 25. Alert MSW of any concerns voiced by visitors/participants related to Behavioral Health.
26. Familiarizes, understands, and implements the Social Services department policies and procedures. 27. Provide mentorship to Social Work Interns on Bienvivir’s Mission and core values.
28. Completes mandatory initial and ongoing training hours as scheduled. 29. Completes company training assignments monthly on Relias. 30. Familiarizes self with, understands and is compliant with Bienvivir policies and procedures. 31. Other duties as assigned by the Social Work Manager and/or PACE Center Director.
/ REQUIREMENTS: 1. A graduate of an accredited university with a bachelor’s degree in social work or related field. 2. Preferred for BSW to become licensed by the Texas State Board of Social Worker Examiners within six months of employment. 3. One year of experience providing Social Services to a frail or elderly population preferred.
A bachelor's degree in social work or a related field is required. Preference is given to candidates with one year of experience with elderly populations and those willing to obtain Texas licensure within six months.
Market context
Behavioral-health openings in Texas often favor licensed clinicians because employers need candidates who can step into patient-facing care with minimal onboarding. Competition is shaped by the required master’s degree, Texas license, and preferred psychiatric experience, plus CPR and CPI certifications. Review the AI-summarized requirements and benefits on this page to save research time, then confirm your license type and highlight any psychiatric or crisis-care experience in your application.
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