SUMMARY

The Social Worker utilizes clinical judgment and expertise to coordinate care management/behavioral health interventions and develops strategies to ensure cost effective, quality care outcomes to patients with complex care needs. In partnership with the OB/GYN, Family Medicine, and Pediatric providers, the Social Worker coordinates care for medically complex children and adults, serves as a resource to guide families and patients through disease self-management, ensures access to an array of community services, administers behavioral health screenings, and conducts and arranges for more detailed assessments when indicated. He/she serves in an expanded health care role, collaborating with specialists, the health care team, patients, and families to facilitate the delivery of quality, efficient, and cost-effective health care.

The services will be provided in accordance with the philosophy, mission, standards, policies, and procedures of the health services ordered by the physician.

ESSENTIAL FUNCTIONS:

a. Plans, implements, coordinates, monitors, and evaluates all options and services with the goal of optimizing the patient’s health. Delivers brief interventions to support necessary lifestyle and behavioral changes. Integrates evidence-based clinical and preventative guidelines, and protocols, in the development of individualized care plans.

b. Actively manages a caseload commensurate with experience and the complexity of the individual patients. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across the continuum and assists patient/families to understand their health care options.

c. Mobilizes patients/significant others to utilize specific strategies to make necessary lifestyle and behavioral changes. Acts as a patient advocate to ensure patient requests are recognized and followed to the greatest extent possible. Identifies and responds to any situation representing risk to the patient or significant others.

d. Responsible for transition of care (TOC) calls, within two (2) business days of discharge, from an acute or semi-acute setting to home. TOC includes medication reconciliation, ensuring PCP or specialist follow-up appointment are arranged, assessing symptoms, teaching warning signs, reviewing discharge instructions, coordination of care, and problem-solving barriers.

e. Works with CMEP leadership to develop and maintain the social service program, drafting supporting policies, procedures, and guidelines for the program. Develops and maintains a thorough knowledge of referral resources throughout the service area.

f. Maintains required documentation for all care management activities, and codes appropriately for services provided.

g. Maintains accurate and timely records including clinical and progress notes according to department policy and codes appropriately for services provided.

h. Develops working relationships with leaders in community resource groups to coordinate care across to the continuum, to offer patients options, tools and resources, and to represent CMU Health at meetings and on various committees that address the social needs of patients.

i. Supports CMEPs commitment to education by occasionally supervising social work students for internships or other educational opportunities.

j. Acts as resource person for other members of the health care team, providing in-service education and consultation in understanding the social and emotional factors related to health problems.

k. Maintains knowledge of the field including Medicare, Medicaid, and other third-party reimbursement sources.

l. Participates in planning and implementing quality improvement activities.

m. Provides positive customer relations in dealing with patients, families, physicians, fell department employees, other hospital departments, referral resources, service agencies, and others.

n. Adheres to department/hospital policies.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

a. Ability to observe, assess, and record symptoms, reactions, and progress.

b. Knowledge of legal and ethical standards for the delivery of medical care.

c. Ability maintain quality, safety, and/or infection control standards.

d. Knowledge of community medical diagnostic and patient care services in are of medical expertise.

e. Knowledge of current principles, methods, and procedures for the delivery of medical evaluation, diagnosis, and treatment in area of expertise.

f. Ability to work both independently and in a team environment.

g. Effective verbal and written communication skills.

QUALIFICATIONS:

a. Master’s degree in social work from an accredited school of social work is required.

b. Current master’s level clinical license with the State of Michigan required or able to obtain within six (6) months of hire date. (Licensed or Limited License)

c. Valid CPR certification is required. Accepted certifications include American Red Cross: BLS for Healthcare Professionals or American Heart Association BLS. Certificates must remain current.

d. Minimum three (3) years of social work experience required with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting; five (5) years preferred.

e. Must have completed (or be willing to complete within 6 months of hire) a certification in perinatal mental health through Post Partum Support International.

f. General computer knowledge and capability to use computer required.

CMU Medical Education Partners is an AA/EO institution, providing equal opportunity to all persons, including minorities, females, veterans, and individuals with disabilities.