Social Worker

SUMMARY:

The Master’s Social Worker (MSW) works independently to assess the needs of, coordinate, and deliver social services for participants and families/caregivers. The MSW is a member of the Interdisciplinary Team (IDT) and participates in the assessment, intervention, management, and review of social service needs. The MSW provides care through a variety of modalities, including but not limited to bio-psychosocial assessment, interventions that include cognitive behavioral techniques, psychoeducation, consultation, and care planning/case management.

SPECIFIC DUTIES AND FUNCTIONS:

• The MSW is a member of the IDT and performs a comprehensive bio-psychosocial assessments at the time of enrollment (initial) and 180-day intervals thereafter. Acute assessments are completed on an as-needed basis and aim to answer specific referral questions. Utilizes measurement-based care.
• Develops and implements appropriate, individual treatment plans for both participants and caregivers, including but not limited to:
  • Counseling (utilizing Motivational Interviewing and CBT techniques)
  • Education
  • Coordination of services in collaboration with the care team
  • Risk Assessment/Crisis Intervention
• Directs case management Issues, including but not limited to:
  • Housing Issues, including identifying least restrictive setting in accordance with participant’s level of income affordability
  • Financial Issues
  • Safety Issues including, but not limited to: symptoms of abuse, neglect or exploitation; ability to live independently; decision-making capacity; any other issues warranting involvement of Adult Protective Services (APS)
  • Psychiatric: changes in mood, behavior, cognition/mental status; suicidal/homicidal ideation; substance use/misuse
  • Caregiver Burden
  • Identifies the need to transfer to a higher level of care.
  • Assists in coordinating discharge planning activities and processes.
  • Educates and counsels the participant and/or caregiver regarding care needs, options and other related problems.
  • Advocates to others on behalf of the participant and demonstrates accountability in resolving participant concerns or issues.
• Works collaboratively to develop and communicate initial impressions, plans of care, changes in care, and progress in a timely fashion.
  • Helps to develop and implement the plan of care with the IDT, participant, and/or caregiver.
  • Completes timely and accurate documentation in the electronic health record (EHR).
  • Communicates changes in participants with IDT and family members.
• Evaluates participant outcomes and progress toward achieving the objectives and goals of the care plan and communicates this information among other members of the IDT.
• Performs other related duties, as assigned by leader(s).

KNOWLEDGE, SKILLS AND ABILITIES:

• Master’s Social Worker from an accredited school of social work.
• Licensed to practice in the State of Michigan. Limited License may be considered depending on experience and number of supervised hours. 
• One year experience working as a clinical social worker, preferably in the field of geriatrics.
• Overall knowledge of case management skills, short term interventions, and principles of human behavior.
• Demonstrated 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 an ability to care for a diverse population.
• Ability to learn and use electronic health record system.
• Proficient in Microsoft Word, Excel, Outlook, PowerPoint.
• Positive, flexible, and solution-focused attitude with ability to collaborate effectively in a team setting.