MSW Care Coordinator I & II

Hope Network Careers•East Lansing, MI

About The Position

The MSW Care Coordinator serves as both the Clinical Social Worker and Care Coordinator for people served by Hope Network. The role provides clinical and psychosocial services, including evaluation, diagnosis, assessment, treatment planning, adjustment counseling, family support, risk assessment, discharge planning, and resource development. The position advocates for patients and families on the interdisciplinary treatment team and helps families understand and cope with challenges related to the person’s condition and recovery. As Care Coordinator, the position manages the rehabilitation process from intake through discharge and follow-up. This includes coordinating and monitoring an individualized, goal-based care plan; facilitating communication among the treatment team, families, external case managers, insurers, physicians, and other stakeholders; coordinating ongoing medical care; maintaining required records and reports; and helping align program recommendations with available funding. The role also maintains knowledge of brain injury recovery, rehabilitation, and professional standards through continuing education. Regular and predictable attendance is an essential requirement.

Requirements

Master’s degree in Social Work (M.S.W.) from an accredited college or university.
Licensed as a Social Worker in Michigan with a clinical designation; an LLMSW may be accepted for Care Coordinator I when clinical supervision is available, with the expectation of actively working toward full licensure.
At least two years of experience in a health or human service field.
Care Coordinator I: two years of case management or related social work experience preferred, in addition to the MSW degree.
Care Coordinator II: three years of case management or related social work experience and full State licensure to practice Social Work.
Experience coordinating care and facilitating communication between caregivers and families.
Demonstrated written and verbal communication skills.
Ability to work effectively with all levels of staff and sensitivity to complex organizational and interpersonal dynamics.
Valid driver’s license and driving record acceptable under Hope Network policy.
Ability to create accurate and detailed notes and records.
Ability to lead a team and provide direction.
Demonstrated problem-solving skills.
Experience with or knowledge of community resources.

Nice To Haves

For Care Coordinator I, two years of case management or related social work experience is preferred.

Responsibilities

Provide clinical services, including evaluation, diagnosis, psychosocial assessment, treatment planning, family assessment and adjustment support, risk assessment, discharge planning, and resource development.
Lead interdisciplinary assessment of the person served and family, including their ability to understand and cope with challenges and support long-term goals.
Provide families with information and progress updates regarding family and consumer goals.
Identify the patient’s pre-injury lifestyle, abilities, skills, values, and interests to support meaningful outcomes.
Plan and coordinate smooth transitions from the program to home or another level of care, including housing, community resources, and stakeholder support for the discharge plan.
When designated, provide or coordinate disability adjustment and psycho-emotional services, including counseling, crisis management, advocacy, education, referrals, and substance misuse intervention.
Serve as a primary family contact and assist with family counseling, education, advocacy, crisis intervention, referrals, discharge planning, benefits applications, and housing opportunities.
Facilitate groups related to psychosocial needs and disability adjustment and provide staff consultation and training through in-services.
Participate in developing psychosocial curricula and family services.
Communicate timely and appropriate information to internal and external team members.
Determine funding parameters, document activities, submit billing, complete clinical reports and daily documentation on time, and meet productivity standards.
Coordinate a goal-based rehabilitation program from intake through discharge and follow-up, maximizing patient satisfaction, quality of care, and cost-effective outcomes.
Drive the individualized rehabilitation program, monitor progress toward goals, support appropriate movement through the continuum of care, and escalate challenges for review.
Lead treatment-team discussions in a goal- and client-focused manner that supports problem solving and cooperation.
Serve as the primary contact for coordination of information and care with outside parties, and keep them informed about progress on the Plan of Care.
Communicate urgent information promptly and prepare reports or Letters of Medical Necessity using required formats and program requirements.
Coordinate ongoing medical care, including appointments, transportation, medical orders, treatment prescriptions, and attendance at appointments when appropriate.
Maintain the HNNR electronic medical record, including the current treatment plan, physician scripts, and required documentation.
Explain financial responsibilities based on funding mix and coverage, work with HNNR Funding to determine funding parameters, and communicate them to stakeholders.
Monitor adherence to funding parameters and appropriate service provision, research unusual or limited funding situations, and adjust program recommendations to fit available funding and the financial guarantor’s needs.
Make internal referrals that create opportunities for HNNR to serve a consumer.
May supervise interns and volunteers and may serve as a rotating on-call emergency contact for residential and community individuals.
Perform other duties as assigned.