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 Perform comprehensive bio‑psychosocial assessments at enrollment (initial) and at 180‑day intervals thereafter; complete acute assessments on an as‑needed basis to answer specific referral questions. Utilize measurement‑based care and develop and implement appropriate, individual treatment plans for both participants and caregivers. Provide counseling using Motivational Interviewing and CBT techniques, education, and coordination of services in collaboration with the care team. Conduct risk assessment and crisis intervention; direct case management and address issues including housing, financial, safety, abuse/neglect, and injury. Assess psychiatric status, including mood, behavior, cognition/mental status, suicidal/homicidal ideation, and substance use/misuse. Evaluate caregiver burden and identify the need to transfer to a higher level of care. Assist in coordinating discharge planning activities and processes. Educate and counsel participants and/or caregivers regarding care needs, options, and related problems. Advocate on behalf of the participant and resolve concerns or issues. Collaborate to develop and communicate initial impressions, plans of care, changes in care, and progress in a timely fashion. Help develop and implement the plan of care with the IDT, participant, and/or caregiver. Complete timely and accurate documentation in the electronic health record (EHR). Communicate changes in participants with IDT and family members; evaluate participant outcomes and progress toward achieving objectives and goals of the care plan. Perform 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). 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 the ability to care for a diverse population. Ability to learn and use an 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. #J-18808-Ljbffr PACE Southeast Michigan