Geriatric Social Worker: Care Coordination & CBT

PACE Southeast Michigan; Detroit (MI); On-site; USD 55,000 - 75,000; Full time

Job summary

PACE Southeast Michigan is seeking a Master’s Social Worker (MSW) in Detroit to assess needs, develop care plans, and coordinate services within an Interdisciplinary Team (IDT). The role involves counseling, discharge planning, and advocacy for participants and caregivers, with strong emphasis on bio-psychosocial assessment and documentation in the EHR.

The ideal candidate holds a MSW, Michigan licensure (or eligible for limited licensure), and at least 1 year of clinical social work experience,

Qualifications

• Master’s degree in Social Work from an accredited school.
• Licensed to practice in the State of Michigan; limited license may be considered.
• One year of clinical social work experience, preferably in geriatrics.
• Strong knowledge of case management, short‑term interventions, and human behavior.
• Proficiency with an electronic health record system.

Responsibilities

• Perform comprehensive bio-psychosocial assessments at enrollment and at 180-day intervals.
• Conduct acute assessments as needed to address referral questions.
• Develop and implement treatment plans, using measurement-based care.
• Provide counseling using Motivational Interviewing and CBT techniques.
• Coordinate services with the care team, addressing housing, finances, safety, and care needs.
• Assist in discharge planning and educate participants and caregivers.
• Advocate for participants and resolve concerns promptly.
• Collaborate with the IDT to communicate care plans and progress.
• Implement the plan of care with the IDT, participant, and caregiver.
• Complete accurate documentation in the EHR and update on status changes.

Skills

Clinical social work

Case management

EHR proficiency

Communication skills

Education

Master’s degree in Social Work

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft PowerPoint

Job description

PACE Southeast Michigan is seeking a Master’s Social Worker (MSW) in Detroit to assess needs, develop care plans, and coordinate services within an Interdisciplinary Team (IDT). The role involves counseling, discharge planning, and advocacy for participants and caregivers, with strong emphasis on bio-psychosocial assessment and documentation in the EHR.

The ideal candidate holds a MSW, Michigan licensure (or eligible for limited licensure), and at least 1 year of clinical social work experience,