About Us
McLaren Health Care is a fully integrated health network committed to quality, evidence-based patient care with locations in Michigan and Indiana. The McLaren system includes 13 hospitals in Michigan, ambulatory surgery centers, imaging centers, a primary and specialty care physician network, commercial and Medicaid HMOs, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, one of only 53 National Cancer Institute-designated comprehensive cancer centers in the U.S.
Care Coordinator - Master of Social Work
This position has the ability to work remotely on either a part- or full-time basis as determined by MMG leadership. Candidate must be located in Michigan
The MSW Care Coordinator will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet the unique biopsychosocial needs, overall goals and values of individual patients. This position focuses on the challenges of high risk populations including frail elderly, chronically ill older adults and patients with behavioral health issues. Ensures efficient service delivery and the highest levels of patient satisfaction.
Essential Functions and Responsibilities:
1. Provides telephonic and face-to-face psychosocial assessment and supportive services to patients as part of an interdisciplinary team.
2. Uses multi-dimensional assessment skills, risk assessment and screening tools to target vulnerable populations.
3. Contributes to the development of a comprehensive plan of care with individualized patient-centered goals. Continually monitors patient/caregiver response to plan of care and makes appropriate revisions.
4. Help patients/caregivers navigate the healthcare system and assists in care coordination activities across the continuum of care.
5. Initiates interventions to address issues and barriers related to social and emotional needs of patients/caregivers.
6. Serves as a resource for patients and providers in researching options for financial assistance, alternative housing, supportive care, and related services.
7. Makes referrals and facilitates access as necessary to resources within the McLaren Healthcare System and community.
8. Provides social support to patients/caregivers in dealing with feelings of loss, adjustment to chronic illness, end of life, family dynamics, and other limitations.
9. Provides crisis intervention and counseling to reduce emotional, financial, or interpersonal stressors
10. Assesses for abuse/neglect, exploitation or abandonment and follows mandatory reporting guidelines.
11. Ensures patients have opportunity to discuss and complete advanced directives
12. Assist patients/caregivers facing end-of-life decisions and supports hospice and palliative care consultations.
13. Act as a liaison to primary care with social, health, and community agencies.
14. Promotes patient engagement and provides self-management support with a focus on empowering the patient/family to build capacity for self-care.
15. Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other disciplinary team members. Fosters a team approach and includes patient/family as active members of the team.
16. Demonstrates excellent written, verbal and listening communication skills, positive relationship building skills, and critical analysis skills.
17. Maintains required documentation of all care management activities.
18. Works with MPP Medical leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.
19. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
20. Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.
Required:
- MSW with a valid unrestricted Michigan license
- Three (3) years MSW experience serving chronically ill patients and extensive knowledge of issues associated with chronic care, disability, and geriatrics.
Preferred:
- Three (3) years’ experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health.
- Telephonic care management experience
- Complex Care Management course completion or CCM
Equal Opportunity Employer
McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.
