Social Worker MSW Home Visit Care Manager

Schedule: Monday, Wednesday, Friday – Part time

About the Department

Social Work (MSW) for home based primary care program. This position will conduct home visits and telephonic care management for patients living in the greater Grand Rapids area. Work as part of an interdisciplinary team to help manage the health care of elderly patients who have difficulty leaving their home for appointments.

Scope of Work

Plans and prioritizes care for individuals and population of clients, focusing on strategies that will promote optimal health within populations. Provides peer support and role modeling related to the development of life skills and health/wellness to individuals and families during home visits, if applicable. Demonstrates expertise, current knowledge in patient care and management of a caseload of clients of varying complexity and seeks to improve patient, family and health systems/community outcomes through the application of educational concepts/skills and preventive care in a managed care environment.

• Visit homes to determine client and family needs. Perform home health assessment, if applicable, including blood pressure, pulse, BMI and foot checks. Develops prioritized plan to meet needs, and provides services. Follow-up with families, community agencies and volunteers to evaluate effectiveness of services provided and plan for future needs.
• Assesses internal and external referrals to identify patient/significant others’ needs, level of intensity, insurance benefits and other patient resources.
• Develops plan of care and makes recommendations to PCPs, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum.
• Assesses the educational needs of clients, families and members of the health care team and develops and implements appropriate teaching strategies or makes appropriate referrals.
• Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner.
• Documents patient data, plan, interventions and outcomes according to department guidelines.
• Maintains knowledge of current trends and developments in the field by reading appropriate books, journals and other literature, and attending related conferences, seminars, etc.
• Ensures that processes and services are continuously monitored for quality, cost effectiveness, and efficiency. Engages in process and quality improvement activities. Makes and implements recommendations to improve operational efficiency and to implement new services for areas of responsibility.

How we will care for you, while you care for our patients

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.

• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Free onsite parking

Qualifications

• Required Masters Social Worker

• 2 years of relevant experience related field Required

• License- Master Social Worker (MSW-Master) - State of Michigan Upon Hire required
• Basic Life Support (BLS) - AHA American Heart Association Healthier Communities and United Lifestyles Only 60 Days required Or
• Basic Life Support (BLS) - ARC American Red Cross Healthier Communities and United Lifestyles Only 90 Days required
• Driver's License - State of Michigan Healthier Communities and United Lifestyles Only Upon Hire required

Primary Location

SITE - 7751 Byron Center - Byron Center

Department Name

Home Based Primary Care - CHMG West

Employment Type

Part time

Shift

Day (United States of America)

Weekly Scheduled Hours

24

Hours of Work

24

Days Worked

M,W, F

Weekend Frequency

N/A

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