MSW Care Coordinator I & II

JOB OBJECTIVE SUMMARY:

The MSW Care Coordinator I & II is a key associate at Hope Network whose primary responsibilities include: serving as the Clinical Social Worker and the Care Coordinator for the person served. 

The Rehab Social Worker role includes the provision of adjustment counseling, and the development of community supports for persons served and families. Clinical services provided include evaluation, diagnosis, treatment planning, family support and adjustment, risk assessments, discharge planning, and resource development. Serves as the patient/family advocate on the Treatment Team.

The Care Coordinator role includes HNNR program intake, needs assessment, service planning, monitoring and evaluation of overall progress, and preparing for discharge. This role establishes and coordinates the interdisciplinary care plan and proactively monitors progress towards goals and objectives. Serves as the representative for communication between the treatment team and the external case manager, insurance adjustor, and other external stakeholders, according to standard procedures for meetings, communications, notifications and written reports. Maintains current understanding of brain injury recovery and rehabilitation, as well as standards of practice through continuing education.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

This is not intended to be an exhaustive listing of job functions. This job description in no way states or implies that these are the only duties to be performed by this employee. The employee is required to follow any other instructions and to perform any other duties as assigned by management.

1. Regular and predictable attendance is an essential requirement of this position.

Clinical Social Worker job functions

1. Provide clinical services including evaluation, diagnosis, psychosocial assessments, treatment planning, family assessment and adjustment support, risk assessments, discharge planning, and resource development.
2. As a member of the inter-disciplinary team, lead the team in the assessment of the person-served and family’s ability to understand and cope with the challenges, as well as ability to provide support in the long-term goals. Provide the family with information and progress updates on progress toward the family and consumer’s goals.
3. Responsible to the team to identify a clear picture of the patient’s pre-injury lifestyle, abilities, skill sets, values and interests to maximize outcomes that are meaningful to the patient and the family.
4. Ensure that the individuals on caseload have a smooth transition as they discharge from our program to home or another level of care. Discharge planning will include but not be limited to:
5. Housing that meets the needs of the individual to include accessibility and supervision.
6. Connecting the individual with community resources required to meet individual needs including social services, health insurance, religious supports, medical and rehabilitation services, transportation, guardians and conservators, etc.
7. Securing support of the discharge plan from all stakeholders including the family, external case managers, physicians, funding sources and the team.
8. If designated, serve as a primary therapist to provide and/or coordinate disability adjustment and psycho-emotional services to individuals. These services may include, but are not limited to:

• Resource Development
• Individual and family counseling
• Substance Abuse intervention and education
• Primary contact for family members
• Information and referral
• Substance misuse counseling, spirituality counseling, etc.
• Crisis management
• Advocacy
• Consumer and family education
• Discharge planning
• Psychosocial consultation to other staff members

1. Serves as the primary family contact for the following items, not limited to:

• Individual/Group/Family counseling
• Dissemination of essential information regarding family
• Parenting skills training
• Family advocacy
• Crisis intervention
• Substance Abuse intervention and education
• Referral to community support resources
• Education specific to the injuries and challenges of the individual
• Assistance with discharge planning
• Assist families/Guardian/Caseworker with SSDI/Medicaid applications/medical benefits.
• Assist families with housing opportunities

1. Serves as facilitator for groups related to psychosocial and disability adjustment.
2. Provides consultation and training to staff through in-services regarding inter-personal, social and behavioral functioning of individuals/families.
3. Participates in the development of psychosocial curriculum and family services.
4. Encourages good communication with internal and external disciplines/persons. Communicates timely and appropriate information to internal team members.
5. Determines funding parameters for each person served, documents own activities and submits for billing. Insures timely completion of all clinical reports and daily documentation. Meets required productivity standard.
6. Other duties as assigned.

Care Coordinator job functions:

1. Responsible for providing a coordinated and seamless goal-based rehabilitation program, from intake to discharge/follow-up, maximizing patient satisfaction, quality of care, and cost-effective outcomes.
2. Drives the individualized rehabilitation program ensuring progress is made towards goals, and movement through the continuum of care occurs as appropriate. Leads the treatment team in a goal and client-focused manner that is conducive to problem solving and cooperation. Proactively escalates for review when the case presents challenges to achieving successful outcomes.
3. Serves as the primary point of contact for coordination of information/care for outside parties including physicians, rehabilitation nurses, adjustors, families/guardians, and other service providers. Keeps all external parties informed at their desired level and frequency of the progress being made on the Plan of Care. Communicates urgent information in a timely fashion and in ways that ensure all team members, including external, receive the information in a timely fashion. 
4. Prepares reports and/or Letters of Medical Necessity that summarize the treatment plan and/or support requests for additional funding. Follows prescribed formats and program requirements.
5. Responsible to oversee the internal and external coordination of on-going medical care including but not limited to scheduling medical appointments and transportation, securing medical orders and treatment prescriptions at required intervals, and attending medical appointments when appropriate.
6. Maintains the HNNR electronic medical record to reflect the current treatment plan, physician scripts, and all required written documentation.
7. Maintains an understanding of the common funding sources for post-acute care including the variations of auto no-fault, commercial health, Medicaid, and worker’s compensation. Able to explain financial responsibilities based on funding mix and coverage, including family responsibility of copayments and deductibles.
8. Works with HNNR Funding to determine funding parameters and communicates these to stakeholders. Monitors team adherence to prescribed parameters and monitors for appropriate service provision. Research unusual or limited funding situations and modify program recommendations to best fit the availability of funding and desires of the financial guarantor.
9. Makes internal referrals that allow HNNR new opportunities to serve a consumer.

Specific Responsibilities-Non-Essential

1. May supervise interns and volunteers.
2. May serve as on-call emergency contact for both residential and community individuals on a rotating basis.

Position Requirements:

1. Minimum Education required: Master’s degree in Social Work (M.S.W.) from an accredited college or university.
2. Licensed as a Social Worker by the State of Michigan (Clinical designation). When clinical supervision can be provided by the program, may accept LLMSW as a MSW Care Coordinator I with the expectation that the candidate is actively working towards full licensure.
3. Demonstrated ability to communicate in both written and verbal formats.
4. Demonstrated ability to work effectively with all levels of staff. Sensitivity to complex organizational and interpersonal dynamics.
5. Valid driver’s license and driving record acceptable according to Hope Network policy.
6. At least two years of experience in a health/human service field.

1. MSW Care Coordinator I – two years of case management or related social work experience preferred, plus holds MSW degree.
2. MSW Care Coordinator II – three years of case management experience or related social work experience and fully licensed by the State to practice Social Work.

1. Experience coordinating care and facilitating communication between caregivers and families.
2. Demonstrated ability in creating accurate and detailed notes/records.
3. Demonstrated ability in leading a team and providing direction.
4. Demonstrated problem solving skills.
5. Demonstrated experience/knowledge of community resources.

Equal Opportunity Employer
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