Social Worker

PACE Southeast Michigan; Eastpointe (MI); On-site; USD 52,000 - 76,000; Full time

Job summary

Pace Southeast Michigan is seeking a Master’s Social Worker to assess, coordinate, and deliver social services for participants and families. The MSW participates in the IDT, develops treatment plans, and uses bio-psychosocial assessments and CBT techniques as part of care planning.

Responsibilities include case management, discharge planning, documentation in the EHR, and advocacy to support participant safety, housing, and care needs. Collaboration with the care team is essential.

Qualifications

• Master’s in Social Work (MSW) from an accredited school.
• Licensed to practice in Michigan (Limited license may be considered).
• One year of clinical social work experience, preferably in geriatrics.
• Knowledge of case management and patient-centered care.
• Ability to evaluate, plan, implement and monitor care.
• Knowledge of laws and regulations; culturally competent.
• Proficient with an EHR system.
• Proficient in Word, Excel, Outlook, PowerPoint.
• Positive, flexible and team-focused attitude.

Responsibilities

• Performs comprehensive bio-psychosocial assessments at enrollment and 180-day intervals.
• Develops and implements treatment plans with counseling, education and care coordination.
• Manages housing, financial, safety, psychiatric, and caregiver issues; discharge planning.
• Educates and counsels participants and caregivers on care needs.
• Advocates on behalf of participants and communicates with IDT.
• Collaborates to develop plans of care and documents progress in the EHR.
• Monitors outcomes and communicates progress to IDT and family.
• Performs other related duties as assigned.

Skills

Clinical social work

Geriatrics experience

Care coordination

Bio-psychosocial assessments

Cultural competence

Team collaboration

EHR documentation

Education

Master’s in Social Work (MSW)

Tools

EHR system

Microsoft Office

Job description

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 theInterdisciplinary 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.