MSW Care Coordinator I & II

Hope Network•East Lansing, MI

About The Position

The MSW Care Coordinator serves as both the Clinical Social Worker and Care Coordinator for people served. In the Clinical Social Worker role, the position provides adjustment counseling and develops community supports for individuals and families. Clinical services include evaluation, diagnosis, treatment planning, family support and adjustment, risk assessment, discharge planning, and resource development. The role advocates for the patient and family on the Treatment Team. In the Care Coordinator role, the position manages program intake, needs assessment, service planning, monitoring and evaluation of progress, and discharge preparation. It establishes and coordinates the interdisciplinary care plan, monitors progress toward goals, and communicates with external case managers, insurance adjustors, and other stakeholders. The coordinator maintains current knowledge of brain injury recovery and rehabilitation and standards of practice through continuing education. The position coordinates goal-based rehabilitation from intake through discharge and follow-up, supports progress across the continuum of care, coordinates medical care and external communications, prepares treatment and funding reports, maintains the electronic medical record, and works with funding staff and stakeholders on service and coverage parameters. It may also involve supervising interns or volunteers and serving as a rotating on-call emergency contact.

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 services field.
Valid driver’s license and driving record acceptable under Hope Network policy.
Demonstrated written and verbal communication skills.
Ability to work effectively with all levels of staff and sensitivity to complex organizational and interpersonal dynamics.
Experience coordinating care and facilitating communication between caregivers and families.
Ability to create accurate and detailed notes and records.
Ability to lead a team and provide direction.
Demonstrated problem-solving skills.
Knowledge of community resources.
For MSW Care Coordinator II: three years of case management or related social work experience and full state licensure to practice Social Work.

Nice To Haves

For MSW 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 understanding of and ability to cope with challenges and support long-term goals; provide progress updates.
Identify the patient’s pre-injury lifestyle, abilities, skills, values, and interests to support meaningful outcomes.
Plan discharge transitions, including accessible and appropriately supervised housing, community resources, stakeholder support, and coordination with families and service providers.
When designated, provide or coordinate disability adjustment and psycho-emotional services, including counseling, substance-use intervention and education, crisis management, advocacy, education, referrals, and psychosocial consultation.
Serve as the primary family contact for counseling, information sharing, advocacy, crisis intervention, referrals, injury-related education, discharge planning, benefits applications, and housing opportunities.
Facilitate psychosocial and disability-adjustment groups and provide staff consultation and training through in-services.
Contribute to psychosocial curriculum and family services; maintain timely communication with internal and external disciplines.
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 satisfaction, quality of care, and cost-effective outcomes.
Lead the treatment team in a client-focused, problem-solving manner; monitor progress and escalate cases when challenges threaten successful outcomes.
Coordinate information and care with outside parties, including physicians, rehabilitation nurses, adjustors, families or guardians, and service providers; communicate progress and urgent information promptly.
Prepare reports and Letters of Medical Necessity supporting treatment plans or requests for additional funding.
Coordinate ongoing medical care, including appointments, transportation, medical orders, prescriptions, and attendance at appointments when appropriate.
Maintain the electronic medical record with the current treatment plan, physician scripts, and required documentation.
Understand common post-acute-care funding sources and explain financial responsibilities based on coverage and funding mix.
Work with Funding to determine and communicate funding parameters, monitor adherence and service provision, research unusual funding situations, and adapt program recommendations as appropriate.
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 and maintain regular, predictable attendance.