Social Worker - Pontiac

PACE Southeast Michigan•Pontiac, MI

13d

About The Position

The Master’s Social Worker (MSW) works independently to assess the needs of participants and their families or caregivers, coordinate social services, and deliver care. As a member of the Interdisciplinary Team (IDT), the MSW participates in assessing, intervening in, managing, and reviewing social service needs. Care may include bio-psychosocial assessments, cognitive behavioral interventions, psychoeducation, consultation, and care planning and case management. The MSW completes comprehensive assessments at enrollment and every 180 days, as well as acute assessments when needed to address specific referral questions. The role develops and implements individualized treatment plans for participants and caregivers, provides counseling and education, coordinates services with the care team, conducts risk assessments and crisis interventions, and directs case management. The MSW addresses housing, financial, safety, psychiatric, and caregiver-burden concerns; identifies when a higher level of care is needed; and assists with discharge planning. The MSW educates and counsels participants and caregivers about care needs and options, advocates for participants, collaborates with the IDT on care plans and changes in care, documents accurately and promptly in the electronic health record, communicates changes and progress, and evaluates outcomes against care-plan goals. The MSW also performs other related duties assigned by leaders.

Requirements

Master’s degree in social work from an accredited school of social work.
Licensed to practice in Michigan; a limited license may be considered depending on experience and supervised hours.
One year of experience working as a clinical social worker.
Knowledge of case management skills, short-term interventions, and principles of human behavior.
Knowledge and skill in evaluating, planning, implementing, and monitoring patient-centered approaches to care.
Knowledge of and compliance with applicable local, state, and federal laws and regulations.
Cultural competence and ability to care for a diverse population.
Ability to learn and use an electronic health record system.
Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint.
Positive, flexible, solution-focused attitude and ability to collaborate effectively in a team setting.

Nice To Haves

Clinical social work experience in geriatrics.

Responsibilities

Complete comprehensive bio-psychosocial assessments at enrollment and at 180-day intervals, and acute assessments as needed.
Use measurement-based care.
Develop and implement individualized treatment plans for participants and caregivers, including counseling using Motivational Interviewing and CBT techniques, education, service coordination, risk assessment, and crisis intervention.
Direct case management and address housing, financial, safety, psychiatric, and caregiver-burden issues.
Identify when a participant needs transfer to a higher level of care.
Assist in coordinating discharge-planning activities and processes.
Educate and counsel participants and caregivers regarding care needs, options, and related problems.
Advocate on behalf of participants and demonstrate accountability in resolving their concerns or issues.
Collaborate with the IDT, participants, and caregivers to develop and implement care plans and communicate impressions, plans, changes, and progress in a timely manner.
Complete timely and accurate documentation in the electronic health record.
Communicate participant changes with the IDT and family members.
Evaluate participant outcomes and progress toward care-plan goals and communicate this information to the IDT.
Perform other related duties as assigned by leaders.