Social Worker

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  • 17-00177
  • Full Time/Contract
  • Behavioral Health
  • Detroit, MI
Job Description
Our client prides itself on delivering comprehensive care to Medicare, Medicaid, and complex-needs patients, with a focus on the underserved population. For well over a decade they work in concert with patients, providers, and health plans. It's all about the harmony of a patient's care, health, and dignity.

Social Worker (Licensed)

The Long Term Supports and Services Supports Coordinator works within a team environment partnering with the Care Coordinator (RN) to advocate and coordinate the continuum of care for our patients. This role requires a high level of interaction with our patients to:
Perform effective outreach to complete necessary health and social assessments

Engage them in the development of an integrated, patient-centered care plan that takes into account needs across the continuum of care (health, social, psycho-social)

Support the patient in achieving their own goals as stated in the care plan as well as monitor adherence to treatment plans or other disease/chronic condition management programs

Work with a multi-disciplinary care team to develop interventions and changes to the care plan in response to patient's needs and promotes positive health outcomes.


  • Perform comprehensive, team-based, and person-centered patient engagement
  • Document patient care plan tasks, goals, and interventions using appropriate mediums (e.g. EMR, historical claims data, outreach logs, etc.) in care coordination record system
  • Identifies caregiver training needs and tracks impact of needs and or training
  • Conduct discharge planning/coordination to ensure all post-discharge LTSS services required are in place Identify the appropriate utilization of resources across the continuum of care
  • Maintain patient/caregiver care plan compliance
  • Participate in quality improvement and evaluation processes
  • Perform and document reassessments, revisions to care plans, and coordinate interdisciplinary care team meetings in accordance with the (health plan) model of care requirements
  • Conduct face to face visits in member's homes at a minimum of every 90 days, or as scheduled per member needs.
  • Complete all mandatory regulatory and other trainings required (including but not limited to: compliance training, first tier downstream and related (FWA) entity training, model of care training, etc.
  • Completes multiple comprehensive assessments to determine qualification for additional supports and services.
  • Collaborates with multiple team members (LTSS Coordinator, Care Coordinator, Patient Care Coordinator, and Management)
  • Assists with identification of high risk members that require a high intensity of care coordination and frequent contact
  • Coordinates community resources depending upon member needs
  • Provides assistance to identify the appropriate LTSS resources across the continuum of care
  • Other duties as assigned


  • LLMSW,LMSW,LBSW license in the State of Michigan.
  • bachelors degree or higher from a CSWE-accredited social work program.
  • Minimum of three (3) years clinical experience, HMO/IPA/Managed Care setting preferred
  • Care Coordination/ Case Management training and/or certification Knowledge community resources. Knowledge of clinical standards of care. Knowledge of Medicaid/Medicare contracts and benefit systems is preferred.
  • Local travel (30%) required for home visits, meetings with families, and other regularly meetings as well as occasional out of town travel are required. Knowledge of CPT, ICD-9 and HCPC codes.
  • Professional, flexible, and patient centered "team player” mentality


  • $65k – $70k
  • Full Time | Contract to Hire


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