Medical Social Worker - Full Time, 40 hours per week - Pediatric Ambulatory Care Navigator - Kalamazoo, MI

About the role

Supports ambulatory care management team and primary care practices in care management and behavioral health delivery of services. Conducts outreach to hospital and emergency department discharge patients and coordinates services as needed. Supports patients across the continuum through behavior health management, psychosocial needs, and community resource needs. Serves in an expanded health care role to collaborate with the ambulatory care management team, primary care practices, specialists, managed care, other members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services.

Responsibilities

• Conducts outreach to hospital and emergency department discharge patients and coordinates services as needed.
• Serves in an expanded health care role to collaborate with the ambulatory care management team, primary care practices, specialists, managed care, other members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services.
• Supports patients across the continuum through behavior health management, psychosocial needs, and community resource needs.
• Assists with and updates, as needed, patient-centered care plans, implements interventions, coordinates care, and monitors and evaluates all options and services with the goal of optimizing the patient’s health status.
• Fulfills other duties as assigned.

Requirements

• Masters of Social Work degree with one-year recent medical or mental health experience preferred or equivalent Master’s degree.
• Licensed Social Work in good standing with the state of Michigan.
• Masters of Social Work (LMSW) or Master’s of Clinical Psychology and Licensed Social Work 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.
• Able to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.
• Critical thinking skills and ability to analyze data sets.
• Able to manage issues/barriers utilizing assessment skills, resources, and standard work.
• Able to implement evidence-based interventions and protocols to support patient health.
• Able to deploy to PCP office as needed to provide support with assessments or high volumes.
• Able to conduct regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.
• Able to maintain documentation for all patient outreach, care management and behavioral health activities in the patients electronic medical record.
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
• Works with various teams across the system as needed to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance patient management.
• Bills appropriate codes based on payor guidelines and direction of leadership.

Qualifications

• Masters of Social Work degree with one-year recent medical or mental health experience preferred or equivalent Master’s degree.
• Licensed Social Work in good standing with the state of Michigan.
• Masters of Social Work (LMSW) or Master’s of Clinical Psychology and Licensed Social Work in the state of Michigan.

Skills

• Customer focused interpersonal skills.
• 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.
• Ability to develop positive, ongoing relationships and set appropriate boundaries with others.
• Able to affect change, work as a productive and effective team member, and adapt to changing needs/priorities.
• Critical thinking skills and ability to analyze data sets.
• Able to manage issues/barriers utilizing assessment skills, resources, and standard work.
• Able to implement evidence-based interventions and protocols to support patient health.
• Able to deploy to PCP office as needed to provide support with assessments or high volumes.
• Able to conduct regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.
• Able to maintain documentation for all patient outreach, care management and behavioral health activities in the patients electronic medical record.
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education.
• Works with various teams across the system as needed to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance patient management.
• Bills appropriate codes based on payor guidelines and direction of leadership.

Benefits

• Up to $5,000.00 Retention Bonus for external candidates.

Pay

• First Shift, Full time

Schedule

• First Shift