Medical Social Worker - Full Time, 40 hours per week - Bronson Family Medicine, The Groves - Kalamazoo

About the role

Responsible for the delivery of care management and behavioral health services in the ambulatory primary care practice setting to a variety of patient populations across the lifespan. Coordinates care to ensure patient/family have access to community services. Administers behavioral health screenings and conducts and arranges for more detailed assessments when indicated. Integrates evidence-based guidelines in the development of individualized patient centered care plans with the patient/family. Monitors/evaluates progress with the goal of optimizing the patient’s health status. Delivers brief interventions to support necessary lifestyle and behavioral changes. Responds to crisis situations in the ambulatory setting. Identifies high-risk psychosocial needs of patients/families. Collaborates with patients, families, and the interdisciplinary care team to ensure understanding of the impact the disease or illness has on the patient's mental and emotional health. Offers a range of brief, solution-focused prevention, treatment, and recovery services for patients with mild to moderate risk factors. Collaborates and works effectively as part of the interdisciplinary health care team to ensure delivery of quality, efficient, and cost-effective team-based health care services. Provides culturally competent clinical services which are relevant to patients/families.

Responsibilities

• Coordinates care to ensure patient/family have access to community services.
• Administers behavioral health screenings and conducts and arranges for more detailed assessments when indicated.
• Integrates evidence-based guidelines in the development of individualized patient centered care plans with the patient/family.
• Makes appropriate referrals to community agencies and other healthcare specialists.
• Collaborates with patients, families, and the interdisciplinary care team to understand each situation and recommend or provide immediate treatment and solution focused interventions.
• Develops and supports a positive work climate and the overall team effort of the department.
• Assumes responsibility for professional development.
• Attends assigned training and meetings.
• Identifies appropriate patients to work with.
• Affords change, works as a productive and effective team member, and adapts to changing needs/priorities.
• Manages complex clinical issues utilizing assessment skills and protocols.
• Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
• Provides education to patients of all ages based on knowledge of growth/development across the lifespan.
• Promotes healthy behaviors in all populations and ensures navigation assistance with community resources.
• Ensures the appropriate follow-up treatment and support is available.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Thoroughly documents each case into the patient's medical record, such as care coordination, care management and behavioral health activities, as appropriate.
• Identifies and provides for learning needs of patients, families, and healthcare coworkers.
• Works with ambulatory care management, managed care, and practice leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance patient care and ensure program & metrics are met.
• Mentors and supervises students as needed/able.
• Bills appropriate codes based on payor guidelines and direction of leadership.

Requirements

• Master of Social Work degree with one-year recent medical or mental health experience preferred or equivalent.
• Licensed Medical Social Worker (LMSW) in the state of Michigan.
• Ability to use word processing, spreadsheets, presentation programs, and other software relevant to the job.
• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
• Demonstrates ability to work autonomously and be directly accountable for practice.
• Demonstrates leader qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
• Demonstrates ability to develop positive, ongoing relationships and set appropriate boundaries with others.
• Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.
• Ability to manage complex clinical issues utilizing assessment skills and protocols.
• Assume responsibility for professional development.
• Attend assigned training and meetings.
• Develop and support a positive work climate and the overall team effort of the department.
• Participates in the development and revisions of departmental processes and standard work.
• Function autonomously on behalf of the providers under the Bronson system and in collaboration with the providers for all identified responsibilities.
• Identify appropriate patients to work with.
• Assess patient needs, coordinates services, and referrals.
• Assess the nature of the crisis and the immediate social/emotional needs and strengths of the patient and family in order to provide appropriate intervention.
• Identify problems surrounding the crisis situation and may act as patient advocate to improve such problems.
• Collaborate with other members of the patient care team to understand each situation recommends or provides immediate treatment and solution focused interventions.
• Work effectively as part of the interdisciplinary healthcare team, collaborating and communicating regularly with the PCP, patient, health care team and other members across the care continuum and community.
• Develop a comprehensive individualized plan of care with targeted interventions for patients.
• Conduct regular follow-ups with patients to evaluate progress and response to plan of care, promote continuity of care and ensure improved health outcomes.
• Evaluate effectiveness of interventions continuously and modify the plan of care as needed.
• Provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
• Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
• Ensure the appropriate follow-up treatment and support is available.
• Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Thoroughly document each case into the patient's medical record, such as care coordination, care management and behavioral health activities, as appropriate.
• Identify and provides for learning needs of patients, families, and healthcare coworkers.
• Works with ambulatory care management, managed care, and practice leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance patient care and ensure program & metrics are met.
• Mentors and supervises students as needed/able.
• Bills appropriate codes based on payor guidelines and direction of leadership.

Qualifications

• Master of Social Work degree with one-year recent medical or mental health experience preferred or equivalent.
• Licensed Medical Social Worker (LMSW) in the state of Michigan.

Skills

• Ability to use word processing, spreadsheets, presentation programs, and other software relevant to the job.
• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
• Demonstrates ability to work autonomously and be directly accountable for practice.
• Demonstrates leader qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
• Demonstrates ability to develop positive, ongoing relationships and set appropriate boundaries with others.
• Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.
• Ability to manage complex clinical issues utilizing assessment skills and protocols.
• Assume responsibility for professional development.
• Attend assigned training and meetings.
• Develop and support a positive work climate and the overall team effort of the department.
• Participates in the development and revisions of departmental processes and standard work.
• Function autonomously on behalf of the providers under the Bronson system and in collaboration with the providers for all identified responsibilities.
• Identify appropriate patients to work with.
• Assess patient needs, coordinates services, and referrals.
• Assess the nature of the crisis and the immediate social/emotional needs and strengths of the patient and family in order to provide appropriate intervention.
• Identify problems surrounding the crisis situation and may act as patient advocate to improve such problems.
• Collaborate with other members of the patient care team to understand each situation recommends or provides immediate treatment and solution focused interventions.
• Work effectively as part of the interdisciplinary healthcare team, collaborating and communicating regularly with the PCP, patient, health care team and other members across the care continuum and community.
• Develop a comprehensive individualized plan of care with targeted interventions for patients.
• Conduct regular follow-ups with patients to evaluate progress and response to plan of care, promote continuity of care and ensure improved health outcomes.
• Evaluate effectiveness of interventions continuously and modify the plan of care as needed.
• Provide patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
• Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
• Ensure the appropriate follow-up treatment and support is available.
• Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Thoroughly document each case into the patient's medical record, such as care coordination, care management and behavioral health activities, as appropriate.
• Identify and provides for learning needs of patients, families, and healthcare coworkers.
• Works with ambulatory care management, managed care, and practice leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance patient care and ensure program & metrics are met.
• Mentors and supervises students as needed/able.
• Bills appropriate codes based on payor guidelines and direction of leadership.

Benefits

• Up to $5,000.00 Retention Bonus External Candidates Only.

Pay

• Commensurate with experience.

Schedule

• First Shift.