Porter Hills-posted 22 days ago
Full-time • Mid Level
Ypsilanti, MI
Religious, Grantmaking, Civic, Professional, and Similar Organizations

The Social Worker delivers direct case management services to participants in the Huron Valley PACE program. Under the supervision of the Social Work Supervisor or designee, this role applies advanced social work knowledge and skills independently. Key responsibilities include participant screening, case management, counseling, and referrals. As a vital member of the Interdisciplinary Team (IDT), the Social Worker contributes to assessments, eligibility determinations, and care planning. This position provides care in various settings, including the day center, participants' homes, and occasionally in hospital settings.

  • Participate in initial assessments, care planning, and periodic reassessments (at least every 6 months), ensuring all documentation is completed before team meetings. Communicate participant changes promptly to support timely care adjustments.
  • Maintain accurate case management records and ensure timely documentation in the Electronic Health Record (EHR) system.
  • Monitor 24-hour care delivery, ensuring continuity of care across service providers and settings.
  • Provide individual and group counseling to help participants and families navigate social, emotional, and health challenges.
  • Connect participants and families with community resources and act as a liaison with external organizations.
  • Foster collaboration among staff and offer guidance on social, emotional, and cultural factors affecting participant care.
  • Advise staff on social service resources and provide consultation to interdisciplinary team members as needed.
  • Participate in developing and refining social work policies to ensure compliance and best practices.
  • Conduct home visits and travel regularly to meet participants in homes, community settings, and external agencies.
  • Facilitate participant enrollment and disenrollment, ensuring adherence to program policies.
  • Assist with Medicaid applications and redetermination, ensuring documentation is submitted accurately.
  • Document participant changes, interventions, and progress per program policies and regulations.
  • Master's degree in social work from an accredited School of Social Work.
  • Current licensure as a Social Worker (LMSW or LLMSW) in the State of Michigan.
  • Valid MI Driver's License and Reliable transportation.
  • CPR certification or willingness to obtain within 90 days of employment.
  • Proficiency in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint).
  • Ability to multi-task in a fast-paced environment while managing multiple priorities effectively
  • Minimum of two (2) years of experience in a health-related field, particularly working with the elderly or frail population.
  • Experience with Electronic Health Records (EHR) and documentation in a clinical setting.
  • Career Growth & Development - Advance your career with tuition assistance and school scholarships up to $3,000 per semester.
  • Wellness Program & Reimbursement - Prioritize your health and well-being, 120 a year!
  • Competitive Benefits for Full-Time Team Members - Enjoy Medical, Vision & Dental Insurance starting on the 1st of the month after 30 days of hire.
  • Retirement Savings Plan - Secure your future with employer contributions.
  • Generous 6 weeks of Flexible time off per year-plus paid holidays on top of that
  • Team Member Referral Bonus Program - Earn $500 when you bring great people to our team!
  • Mileage Reimbursement - Offered for work-related travel
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