The Medical Social Worker supports the ambulatory care management team by conducting patient outreach, coordinating care, and managing behavioral health needs. They are responsible for developing patient-centered care plans, performing clinical interventions, and monitoring health outcomes to prevent hospital readmissions.
Requirements summary
Candidates must hold a Master of Social Work degree and be a Licensed Social Worker in the state of Michigan. At least one year of recent medical or mental health experience is preferred.
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Location BHG Bronson Healthcare Group 6901 Portage Road Title Medical Social Worker - Full Time, 40 hours per week - Pediatric Ambulatory Care Navigator - Kalamazoo, MI Supports ambulatory care management team and primary care practices in care management and behavioral health delivery of services.
Conducts outreach to hospital and emergency department discharge patients and coordinates services as needed.
Supports patients across the continuum through behavior health management, psychosocial needs, and community resource needs.
Serves in an expanded health care role to collaborate with the ambulatory care management team, primary care practices, specialists, managed care, other members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services.
Assists with and updates, as needed, patient-centered care plans, implements interventions, coordinates care, and monitors and evaluates all options and services with the goal of optimizing the patient’s health status.
Follows evidence-based clinical guidelines, preventive guidelines, and protocols in care delivery for the patient.
Supports the team as needed by administering behavioral health screenings and arranges for more detailed assessments when indicated.
Identifies high-risk psychosocial needs of patients/families to coordinate appropriate services.
Provides support to the team in targeted interventions to increase self-management and prevent hospitalization, emergency room visits, and/or readmissions.
Coordinates care across settings and helps patient/families understand health care options.
Deploys to PCP office as needed to provide support with assessments or high volumes.
Emphasis of duties may vary depending upon the area of assignment.
Benefits
Sign-on bonus
Masters of Social Work degree with one-year recent medical or mental health experience preferred or equivalent Master’s degree.
Licensed Social Work in good standing with the state of Michigan.
Masters of Social Work (LMSW) or Master’s of Clinical Psychology and Licensed Social Work in the state of Michigan.
Ability to use word processing, spreadsheets, presentation programs, and other software relevant to the job.
Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.
Demonstrates ability to work autonomously and be directly accountable for practice.
Demonstrates leader qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.
Demonstrates ability to develop positive, ongoing relationships and set appropriate boundaries with others.
Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities Critical thinking skills and ability to analyze data sets.
Ability to manage issues/barriers utilizing assessment skills, resources, and standard work.
Ability to implement evidence-based interventions and protocols to support patient health.
Flexibility to adapt to the needs of the department.
Function autonomously on behalf of the providers under the Bronson system and in collaboration with the providers for all identified responsibilities.
Identify patients for hospital/ED outreach follow-up through ADT reports and prioritize using risk stratification tools.
Provide follow-up with patient/family when patient transitions from one setting to another.
Completes timely post-hospital follow-up: schedule PCP or specialist follow-up appointments; assess for ongoing or new symptoms; review warning signs and discharge instructions, complete medication reconciliation, coordinate care, and problem solve barriers.
Identify high risk patient acuity and eligibility to initiate enrollment in Care Management.
Connect patients with care manager and/or other resources as appropriate.
Identify gaps in care for patients and support closing gaps.
Identify patient needs and coordinate resources or referrals as appropriate to support the physical and/or psychosocial need of the patient.
Provides patient self-management support with a focus on empowering the patient/family to build capacity for self-care.
As needed develop goals and interventions with patient.
Implement clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
Assess the nature of a crisis and the immediate social/emotional needs and strengths of the patient and family in order to provide appropriate intervention.
Perform appropriate screenings based on patient population and need.
Deploys to PCP office as needed to provide support with assessments or high volumes. ·Conduct regular follow-ups with patients to evaluate progress and response to plan of care, promote continuity of care and ensure improved health outcomes.
Coordinate patient care through ongoing collaboration with care team, PCP, patient/family, community, and other members of the health care system.
Fosters a team approach and includes patient/family as active members of the team.
Outreach and engage assigned patient population and identify care needs.
Conduct regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.
Maintains documentation for all patient outreach, care management and behavioral health activities in the patients electronic medical record.
Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education Works with various teams across the system as needed to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance patient management.
Bill appropriate codes based on payor guidelines and direction of leadership.
Shift First Shift Time Type Full time Sign-On Bonus External Candidates Only: Up to $5,000.00 Retention Bonus External Candidates Only, $5,000.00 Scheduled Weekly Hours 40 Cost Center 1287 Centralized Disease and Care Management (BHG) Agency Use Policy and Agency Submittal Disclaimer Bronson Healthcare Group and its affiliates (“Bronson”) strictly prohibit the acceptance of unsolicited resumes from individual recruiters or third-party recruiting agencies ("Recruiters") in response to job postings or word of mouth.
Unsolicited resumes sent to any employee of Bronson by Recruiters, without both a valid written agreement with Bronson and a direct written request from the Bronson Talent Acquisition Department for a specific job position, will be considered the property of Bronson.
Furthermore, no fees will be owed or paid to Recruiters who submit resumes for unsolicited candidates, even if those candidates are hired.
This policy applies regardless of whether the Recruiter has a pre-existing agreement with Bronson.
Only candidates submitted through a specific written agreement with the Bronson Talent Acquisition Department for a named position are eligible for fee consideration.
Bronson Healthcare is a community-owned, not-for-profit health system that has been serving southwest Michigan since 1900.
Today, with a workforce of 9,000 people and 1,500 medical staff members, it is the area’s largest employer and leading healthcare system.
Bronson provides care in virtually every specialty and offers a full range of services from primary care to critical care at more than 100 locations.
Bronson’s exceptionally high quality standards enable us to do what’s right for our patients and their families.
We are empowered as individuals and as teams, to apply our skills and experience so that every patient receives safe, timely and effective treatment.
What’s more, our state-of-the-art, technology and evidence-based processes give us the tools we need to deliver the right care, at the right time.
By putting each patient and their family at the center of our work, we demonstrate the dignity and respect we have for each individual we serve.
This unwavering commitment to serving others combined with our unique healing environment helps make the patient experience here an exceptional one.
The excellence and Positivity of our employees and medical staff has contributed to Bronson Healthcare being ranked by Forbes as one of America’s Best-In-State Employers (2022-23), by Newsweek as one of America’s Greatest Workplaces for Women (2023) and by the National Association for Business Resources as one of the 2023 Top 101 Best and Brightest Companies to Work For.
