About The Position

Responsible for the delivery of care management and behavioral health services in the ambulatory medical practice setting to a variety of patients including pediatric, adolescent, adult, and geriatric populations. Coordinates care to ensure patient/family have access to an array of community services. Administers behavioral health screenings and conducts and arranges for more detailed assessments when indicated. Integrates evidence-based guidelines in the development of individualized patient centered care plans with the patient/family and monitors/evaluates progress with the goal of optimizing the patient’s health status. Delivers brief interventions to support necessary lifestyle and behavioral changes. Responds to crisis situations in the ambulatory setting. Identifies high-risk psychosocial needs of patients/families. Collaborates with patients, families, and the interdisciplinary care team to ensure understanding of the impact the disease or illness has on the patient's mental and emotional health. Offers a range of brief, solution-focused prevention, treatment, and recovery services for patients with mild to moderate risk factors. Collaborates and works effectively as part of the interdisciplinary health care team to ensure delivery of quality, efficient, and cost-effective team-based health care services. Provides culturally competent clinical services which are relevant to patients/families. Emphasis of duties may vary depending upon the area of assignment.

Requirements

  • Limited License Social Work with the following requirements: minimum one-year medical or mental health experience.
  • Required to be fully licensed within two and a half years of hire including state required supervision hours and licensing exam.
  • Limited Licensed Social Work in good standing with the state of Michigan.
  • Masters of Social Work or Master’s of Clinical Psychology and Limited Licensed Social Work in the state of Michigan.
  • Must show with proof of passing licensing test.
  • Ability to utilize word processing, spreadsheet, presentation programs, databases, 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 leadership 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, longitudinal relationships and set appropriate boundaries with patients/families.
  • Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.
  • Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities

Responsibilities

  • Assesses the nature of the crisis and the immediate social/emotional needs and strengths of the patient and family in order to provide appropriate intervention.
  • Performs appropriate screenings based on patient population and need.
  • Identifies problems surrounding the crisis situation and may act as patient advocate to ameliorate such problems.
  • Collaborates with other members of the patient care team to understand each situation from different perspectives and recommends or provides immediate treatment and solution focused interventions.
  • Works effectively as part of the interdisciplinary healthcare team, collaborating and communicating regularly with the team and other members on cases and as issues arise.
  • Identifies the need for, develops plan of care and makes referrals to community agencies and other healthcare specialist and plans to ensure the appropriate follow-up treatment and support is available and provided for after leaving the department.
  • Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community.
  • Responsible for developing a comprehensive individualized plan of care and targeted interventions.
  • Continually monitors patient/family response to plan of care, and revises the care plan as indicated.
  • Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.
  • Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
  • Thoroughly documents each case and enters appropriate information into the patient's medical record.
  • Participates in the development of departmental policies, procedures and protocols.
  • Identifies and provides for learning needs of patients, families, and healthcare coworkers.
  • Identifies appropriate patients to work with.
  • Critical thinking skills and ability to analyze complex data sets.
  • Ability to manage complex clinical issues utilizing assessment skills and protocols
  • Works with ambulatory care management, managed care, and practice leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance patient care and ensure programs & metrics are met.
  • Assumes responsibility for professional development.
  • Develops and supports a positive work climate and the overall team effort of the department.
  • Mentors and supervises students.
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