Medical Social Worker - Full Time, 40 hours per week - Pediatric Ambulatory Care Navigator - Kalamazoo, MI

Bronson Healthcare

About The Position

Supports ambulatory care management team and primary care practices in care management and behavioral health delivery of services. Conducts outreach to hospital and emergency department discharge patients and coordinates services as needed. Supports patients across the continuum through behavior health management, psychosocial needs, and community resource needs. Serves in an expanded health care role to collaborate with the ambulatory care management team, primary care practices, specialists, managed care, other members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assists with and updates, as needed, patient-centered care plans, implements interventions, coordinates care, and monitors and evaluates all options and services with the goal of optimizing the patient’s health status. Follows evidence-based clinical guidelines, preventive guidelines, and protocols in care delivery for the patient. Supports the team as needed by administering behavioral health screenings and arranges for more detailed assessments when indicated. Identifies high-risk psychosocial needs of patients/families to coordinate appropriate services. Provides support to the team in targeted interventions to increase self-management and prevent hospitalization, emergency room visits, and/or readmissions. Coordinates care across settings and helps patient/families understand health care options. Deploys to PCP office as needed to provide support with assessments or high volumes. Emphasis of duties may vary depending upon the area of assignment.

Requirements

Masters of Social Work degree with one-year recent medical or mental health experience preferred or equivalent Master’s degree.
Licensed Social Work in good standing with the state of Michigan.
Masters of Social Work (LMSW) or Master’s of Clinical Psychology and Licensed Social Work in the state of Michigan.
Ability to use word processing, spreadsheets, presentation programs, and other software relevant to the job.
Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
Demonstrates ability to work autonomously and be directly accountable for practice.
Demonstrates leader qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
Demonstrates ability to develop positive, ongoing relationships and set appropriate boundaries with others.
Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities
Critical thinking skills and ability to analyze data sets.
Ability to manage issues/barriers utilizing assessment skills, resources, and standard work.
Ability to implement evidence-based interventions and protocols to support patient health.
Flexibility to adapt to the needs of the department.
Function autonomously on behalf of the providers under the Bronson system and in collaboration with the providers for all identified responsibilities.

Responsibilities

Identify patients for hospital/ED outreach follow-up through ADT reports and prioritize using risk stratification tools.
Provide follow-up with patient/family when patient transitions from one setting to another.
Completes timely post-hospital follow-up: schedule PCP or specialist follow-up appointments; assess for ongoing or new symptoms; review warning signs and discharge instructions, complete medication reconciliation, coordinate care, and problem solve barriers.
Identify high risk patient acuity and eligibility to initiate enrollment in Care Management.
Connect patients with care manager and/or other resources as appropriate.
Identify gaps in care for patients and support closing gaps.
Identify patient needs and coordinate resources or referrals as appropriate to support the physical and/or psychosocial need of the patient.
Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
As needed develop goals and interventions with patient.
Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
Assess the nature of a crisis and the immediate social/emotional needs and strengths of the patient and family in order to provide appropriate intervention.
Perform appropriate screenings based on patient population and need.
Deploys to PCP office as needed to provide support with assessments or high volumes.
Conduct regular follow-ups with patients to evaluate progress and response to plan of care, promote continuity of care and ensure improved health outcomes.
Coordinate patient care through ongoing collaboration with care team, PCP, patient/family, community, and other members of the health care system.
Fosters a team approach and includes patient/family as active members of the team.
Outreach and engage assigned patient population and identify care needs.
Conduct regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.
Maintains documentation for all patient outreach, care management and behavioral health activities in the patients electronic medical record.
Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education
Works with various teams across the system as needed to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance patient management.
Bill appropriate codes based on payor guidelines and direction of leadership.