Social Worker - Detroit ThomeRivertown

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

Overview

The Master’s Social Worker (MSW) works independently to assess the needs of 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 bio-psychosocial assessment, interventions that include cognitive behavioral techniques, psychoeducation, consultation, and care planning/case management.

Responsibilities

• Perform comprehensive bio-psychosocial assessments at enrollment and at 180‑day intervals thereafter.
• Conduct acute assessments as needed to address specific referral questions.
• Utilize measurement‑based care and develop appropriate, individual treatment plans for participants and caregivers.
• Provide counseling using Motivational Interviewing and CBT techniques.
• Coordinate services in collaboration with the care team, addressing housing, financial, safety, psychiatric, substance‑use, caregiver burden, and other relevant issues.
• Assist in discharge planning activities and processes.
• Educate and counsel participants and/or caregivers regarding care needs, options, and related problems.
• Advocate on behalf of participants and resolve concerns in a timely, accountable manner.
• Collaborate with the IDT to develop and communicate initial impressions, care plans, changes in care, and progress.
• Implement the plan of care with the IDT, participant, and/or caregiver.
• Complete timely and accurate documentation in the electronic health record (EHR).
• Communicate participant status changes within the IDT and to family members.
• Evaluate participant outcomes and progress toward achieving care plan objectives and goals.
• Perform other related duties as assigned by leader(s).

Qualifications

• Master’s degree in Social Work from an accredited school.
• Licensed to practice in the State of Michigan; limited license may be considered based on experience and supervised hours.
• One year of clinical social work experience, preferably in geriatrics.
• Strong knowledge of case management skills, short‑term interventions, and principles of human behavior.
• Demonstrated ability to evaluate, plan, implement, and monitor patient‑centered approaches to care.
• Knowledge of and compliance with applicable local, state, and federal laws and regulations.
• Cultural competence and ability to care for a diverse population.
• Proficiency in using an electronic health record system.
• Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint.
• Positive, flexible, solution‑focused attitude with effective collaboration skills.