What are the responsibilities and job description for the Social Worker position at Michigan Primary Care Partners?
Care Management Social Worker (LMSW or LBSW)
Locations: Big Rapids, Reed City, Canadian Lakes (Stanwood), Michigan
About Us
Michigan Primary Care Partners (MPCP) is a well-established, independent healthcare organization specializing in adult primary care and internal medicine. Founded in 1998, MPCP operates as a Patient-Centered Medical Home (PCMH) serving communities across West Michigan.
We are proud to have been voted Best Place to Work in both the 2024 and 2025 Readers’ Choice Awards, along with multiple community recognitions including Best Outpatient Medical Facility, Best Family Doctor, Best Surgeon, Best Physician Assistant, Best Nurse Practitioner, Best Pharmacist, and Best Registered Nurse.
As an independent, physician-led practice, MPCP is committed to delivering accessible, high-quality, and cost-effective healthcare while fostering a supportive and collaborative workplace culture.
Our team-based care model emphasizes prevention, proactive treatment, and strong partnerships between patients, families, and healthcare providers.
Position Summary
The Care Management Social Worker works as part of MPCP’s integrated primary care team, collaborating closely with physicians, nurse practitioners, physician assistants, nurses, pharmacists, and other care team members to support patients with complex medical, behavioral, and social needs.
This role participates in MPCP’s care management and population health programs, supporting patients with complex medical and psychosocial needs through coordinated, team-based care.
The position focuses on identifying and addressing psychosocial barriers to care, coordinating community resources, and assisting patients with chronic and complex medical conditions in navigating the healthcare system.
This role emphasizes addressing social determinants of health, supporting patient self-management, and improving overall health outcomes through coordinated care.
The position focuses on care coordination, patient support, and brief behavioral health interventions within the primary care setting.
Schedule: Monday – Friday
No nights, weekends, or holidays
Key Responsibilities
Support MPCP’s mission of providing accessible, high-quality healthcare services.
Identify and address psychosocial needs and social determinants of health including housing instability, transportation challenges, food insecurity, financial barriers, and access to medications.
Develop and maintain relationships with community agencies and maintain an up-to-date resource library.
Collaborate with providers, nurses, pharmacists, and other care team members to develop comprehensive patient-centered care plans.
Provide counseling, education, and support to patients and families related to coping strategies, behavioral health needs, and social challenges impacting health outcomes.
Assist patients in navigating healthcare services, insurance issues, and community support systems.
Coordinate referrals to appropriate community programs and support services.
Support patient engagement and self-management through coaching, education, and motivational support.
Assist with care transitions including hospital discharge coordination and follow-up support to reduce hospital readmissions.
Document all care management activities and patient encounters within the electronic health record (EHR), including appropriate ICD-10 diagnosis selection and care management documentation supporting applicable CPT billing when appropriate.
Participate in interdisciplinary care team meetings and quality improvement initiatives.
Perform other duties consistent with MPCP’s mission as assigned.
Requirements & Qualifications
Licensed Social Worker in the State of Michigan (LMSW or LBSW) required.
Licensure must be in good standing with the
Michigan Department of Licensing and Regulatory Affairs.
Minimum of 1 year experience in social work, care management, or community resource coordination preferred.
Experience in primary care, outpatient healthcare, population health, or Patient-Centered Medical Home (PCMH) environments preferred.
Skills & Abilities
Strong knowledge of community resources and social support services.
Excellent organizational, communication, and interpersonal skills.
Ability to work effectively with individuals from diverse backgrounds.
Ability to identify psychosocial barriers to care and assist patients in accessing appropriate support services.
Demonstrated ability to work independently, exercise sound judgment, and function as part of a multidisciplinary care team.
Proficiency with electronic health records (EHR) and computer systems.
Working knowledge of ICD-10 diagnosis documentation and healthcare care management workflows preferred.
Commitment to patient confidentiality and adherence to HIPAA standards.
Other Requirements
Willingness to travel between MPCP locations as needed (Big Rapids, Reed City, and Canadian Lakes/Stanwood).
Compensation
$24 – $34 per hour depending on experience and licensure
Higher starting wage may be considered for LMSW candidates or candidates with prior healthcare care management experience.
Why Join MPCP?
Voted Best Place to Work in the 2024 and 2025 Readers’ Choice Awards
Independent, physician-led practice with a patient-first culture.
Collaborative, team-based environment where your role directly impacts patient outcomes.
Stable and growing organization with strong community roots.
Opportunities for professional growth and participation in innovative care management programs.
Paid holidays.
Pay: $24.00 - $30.00 per hour
Benefits:
- 401(k) matching
- Dental insurance
- Flexible schedule
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
Salary : $24 - $34