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
- Perform comprehensive bio‑psychosocial assessments at enrollment (initial) and at 180‑day intervals thereafter; complete acute assessments on an as‑needed basis to answer specific referral questions.
- Utilize measurement‑based care and develop and implement appropriate, individual treatment plans for both participants and caregivers.
- Provide counseling using Motivational Interviewing and CBT techniques, education, and coordination of services in collaboration with the care team.
- Conduct risk assessment and crisis intervention; direct case management and address issues including housing, financial, safety, abuse/neglect, and injury.
- Assess psychiatric status, including mood, behavior, cognition/mental status, suicidal/homicidal ideation, and substance use/misuse.
- Evaluate caregiver burden and identify the need to transfer to a higher level of care.
- Assist in coordinating discharge planning activities and processes.
- Educate and counsel participants and/or caregivers regarding care needs, options, and related problems.
- Advocate on behalf of the participant and resolve concerns or issues.
- Collaborate to develop and communicate initial impressions, plans of care, changes in care, and progress in a timely fashion.
- Help develop and implement the plan of care with the IDT, participant, and/or caregiver.
- Complete timely and accurate documentation in the electronic health record (EHR).
- Communicate changes in participants with IDT and family members; evaluate participant outcomes and progress toward achieving objectives and goals of the care plan.
- Perform 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).
- 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 the ability to care for a diverse population.
- Ability to learn and use an 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.