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

• Performs comprehensive bio‑psychosocial assessments at enrollment and at 180‑day intervals.
• Conducts acute assessments as needed to answer specific referral questions.
• Utilizes measurement‑based care.
• Develops and implements individualized treatment plans for participants and caregivers, including counseling (motivational interviewing and CBT techniques) and psychoeducation.
• Coordinates services in collaboration with the care team and performs risk assessment and crisis intervention.
• Manages case‑management issues such as housing, financial, and safety concerns, and initiates involvement of Adult Protective Services (APS) when warranted.
• Assesses psychiatric changes, suicidal/homicidal ideation, substance misuse, and caregiver burden.
• Assists in coordinating discharge planning and related processes.
• Educates and counsels participants and/or caregivers regarding care needs, options, and related problems.
• Advocates on behalf of participants and resolves concerns or issues.
• Communicates with the IDT and family members regarding care plans, changes in care, and progress.
• Documents timely and accurately in the electronic health record (EHR).
• Evolves and evaluates participant outcomes and progress toward achieving objectives and goals of the care plan.
• Performs other related duties as assigned by leaders.

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’s 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 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, and solution‑focused attitude with ability to collaborate effectively in a team setting.