- Full Time/Contract
- Behavioral Health
- Detroit, MI
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
COMPENSATION | POSITION CLASSIFICATION
- $65k – $70k
- Full Time | Contract to Hire