Social Worker - Center Line

**SUMMARY:** The Master’s Social Worker (MSW) works independently to assess the needs of, coordinate, and deliver social services for participants and families/caregivers. The MSW is a member of the Interdisciplinary Team (IDT) and participates in the assessment, intervention, management, and review of social service needs. The MSW provides care through a variety of modalities, including but not limited to bio-psychosocial assessment, interventions that include cognitive behavioral techniques, psychoeducation, consultation, and care planning/case management. **SPECIFIC DUTIES AND FUNCTIONS:** - The MSW is a member of the IDT and performs a comprehensive bio-psychosocial assessments at the time of enrollment (initial) and 180-day intervals thereafter. Acute assessments are completed on an as-needed basis and aim to answer specific referral questions. Utilizes measurement-based care. - Develops and implements appropriate, individual treatment plans for both participants and caregivers, including but not limited to: - Counseling (utilizing Motivational Interviewing and CBT techniques) - Education - Coordination of services in collaboration with the care team - Risk Assessment/Crisis Intervention - Directs case management Issues, including but not limited to: - Housing Issues, including identifying least restrictive setting in accordance with participant’s level of income affordability - Financial Issues - Safety Issues including, but not limited to: symptoms of abuse, neglect or exploitation; ability to live independently; decision-making capacity; any other issues warranting involvement of Adult Protective Services (APS) - Psychiatric: changes in mood, behavior, cognition/mental status; suicidal/homicidal ideation; substance use/misuse - Caregiver Burden - Identifies the need to transfer to a higher level of care. - Assists in coordinating discharge planning activities and processes. - Educates and counsels the participant and/or caregiver regarding care needs, options and other related problems. - Advocates to others on behalf of the participant and demonstrates accountability in resolving participant concerns or issues. - Works collaboratively to develop and communicate initial impressions, plans of care, changes in care, and progress in a timely fashion. - Helps to develop and implement the plan of care with the IDT, participant, and/or caregiver. - Completes timely and accurate documentation in the electronic health record (EHR). - Communicates changes in participants with IDT and family members. - Evaluates participant outcomes and progress toward achieving the objectives and goals of the care plan and communicates this information among other members of the IDT. - Performs other related duties, as assigned by leader(s). **KNOWLEDGE, SKILLS AND ABILITIES:** - Master’s Social Worker from an accredited school of social work. - Licensed to practice in the State of Michigan. Limited License may be considered depending on experience and number of supervised hours. - One year experience working as a clinical social worker, preferably in the field of geriatrics. - Overall knowledge of case management skills, short term interventions, and principles of human behavior. - Demonstrated knowledge and skill in evaluating, planning, implementing, and monitoring patient-centered approaches to care. - Knowledge of and compliance with applicable local, state, and federal laws and regulations. Cultural competence and an ability to care for a diverse population. - Ability to learn and use electronic health record system. - Proficient in Microsoft Word, Excel, Outlook, PowerPoint. - Positive, flexible, and solution-focused attitude with ability to collaborate effectively in a team setting.