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Bienvivir All-Inclusive Senior Health

SilkRoad Technology Activation

Social Worker - LMSW

Social Services

El Paso
ID: 719-374

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.  


Bienvivir is currently accepting applications for the following position:




Under the supervision of the Social Work Manager, the Social Worker – MSW is responsible for providing outreach, social services, crisis, counseling and intervention, advocacy, and case management to participants enrolled in Bienvivir and their families. It is the responsibility of the Social Worker to ensure that cultural/ethical considerations of participants are addressed in long term care programming, planning, and treatment.



Case Management:

1. Provides case management services to an assigned caseload of Participants.

2. Completes Home Safety Screen as per fall policy if no Home Health services are in place.

3. Completes Plan of Care review and Signature Page with the participant, placement facility and/or participant representative within 15 business days of dated IDT completed Care Plan.

4. Visits participants that are hospitalized as indicated and begins the discharge planning process to ensure a smooth transition upon discharge.

5. Serves as a liaison to the participant’s family via home visits, family conferences and telephone contacts, utilizing appropriate protocols to keep all parties informed.

6. Assists with Permanent and Respite Placements as indicated.

7. Complete Placement cost contract and submit for approval.

8. Attends facility case conferences as necessary.

9. Completes Medical Alert referral when approved by the IDT.

10. Completes disenrollment documents (death and non-death).

11. Completes MSUR Service Delivery Day Unit form on a timely basis.

12. Provides appropriate documentation for internal and external reporting purpose such as psychosocial assessments, progress notes, and reports of changes in status/condition within a 24-hour time frame of contact.

13. Completes interventions on care plan within 3 months of dated IDT completed Care Plan.

14. Assists participants with reports that are required on an annual basis (i.e., Medicaid renewals, recertifications, etc.)

15. Identifies participants eligible for transfer and initiate transfer checklist.

16. Refers participant and family members to community resources as needed.

17. Performs on-call duties from Friday to Friday, reporting physician on-call and any other staff person who is on call during the same time; Cooperates with other disciplines to trouble-shoot and resolve difficulties that arise while performing on-call duties.

IDT Responsibilities:

18. As a member of the IDT, meets to develop a comprehensive Plan of Care in collaboration with the Participant and/or designated representative listing all care needed to meet the participant's medical, physical, emotional, and psychosocial needs.

19. Completes an initial in-person comprehensive assessment on each participant promptly following the enrollment. Evaluates the participant in-person and develops a discipline specific assessment of the participant’s health and social status.

20. Conducts semi-annual, in-person reassessments, as well as unscheduled reassessments based on a significant change in health condition or psychosocial status of the participant.

21. Is an integral part of the IDT that meets daily to assess for participant needs.

22. Files APS reports on abuse, neglect, and exploitation, and educates staff on process to file APS reports.

Behavioral Health:

23. Conducts and completes initial psychosocial assessments and develops corresponding treatment plans within ten (10) working days of the participant’s enrollment.

24. Completes routine assessments and plans of care for each participant by the scheduled I/A date; completes re-assessments and plans of care within seven-two (72) hours of participant’s or family’s request, if such is the case.

25. Initiates and completes episodic care plan updates as indicated.

26. Participates as an integral member of the multidisciplinary team to diagnose problems, formulate treatment plans, and evaluate progress of participants.

27. Interprets the social aspects of participant condition or status changes to the IDT at the I/A meetings or the daily participant Plan of Care Committee (PCP) and to family/caregiver as expeditiously as required by the participant’s condition.

28. Provides advanced directives education on at least a biannual basis and assists with completion as indicated.

29. Participates in ongoing communication to participant/decision maker about Participant Rights, Grievance and Appeals Process, and Care Planning.

30. Assists with transition to End of Life Care

Community Liaison:

31. Establishes and maintains a positive relationship with BSHS Contracted Assisted Living/Foster Homes/ Nursing Home Facilities to ensure that when participants need placement or respite, their needs will be met appropriately and on a timely basis.

32. Serves as a liaison and advocate for participants and their families with agencies such as Social Security Administration, Health and Human Services Commission, the Housing Authority, Adult Protective Services, Probate Court, etc.

33. In collaboration with Human Resources, assists in facilitating staff in-services by contacting outside presenters who have the expertise in providing services to the elderly.


34. Assists in training/supervision of social work interns (students) and new hires, coordinating their assignments with the Social Work Manager.

35. Understands and implements the Social Work Department policies and procedures.

Emergency Preparedness:

36. Is identified as a Search Warden by the Emergency Management Team and participates in emergency planning as indicated (natural disaster, emergency center closures, evacuations, etc.)

Professional Responsibilities:

37. Responsible for maintaining current Social Work licensure training hours as required by the Texas State Board of Social Work Examiners.

38. Completes mandatory initial and ongoing training hours as scheduled.

39. Other duties as assigned by the Social Work Manager and/or PACE Center Director.



A. A graduate of an accredited university with a master’s degree in social work and licensed by the Texas State Board of Social Worker Examiners.

B. One year’s experience in providing Social Services to a frail or elderly population preferred.

C. Knowledge and experience working with the geriatric population and family systems.

D. Knowledge of community referral system for community services.

E. Knowledge and experience working with case management.

F.  Must be bilingual (Spanish/English).

This position is located at 2300 McKinley Ave., El Paso. View the Google Map in full screen.