Care Manager - Social Work (LMSW) Southwest Health Center - CIN * Days (M-F, 8am -5pm) - 40hrs/wk

General Summary: Under the direction of the PHO Director, the MSW Care Manager provides social work services to patients and their families in an ambulatory setting. The MSW Care Manager performs care coordination, clinical assessments and therapeutic interventions with the goal of optimizing patient’s physical and mental health. The MSW Care Manager serves as the mental health specialist and community resource expert. This integral role expands primary care’s scope of practice by focusing on mental health and social needs to ensure the delivery of comprehensive, efficient and quality care. Requirements: Demonstrates leadership qualities through excellent time management, work delegation and organization skills. Demonstrates creative problem solving, critical thinking skills, and excellent written and verbal communication. Comprehensive knowledge of community resources. Knowledge of chronic medical and mental health conditions. Ability to triage and manage complex clinical issues utilizing assessment skills and protocols. Ability to work independently as well as in a team environment. Ability to adapt to changes in health care with the goal of improving quality, efficiency and cost effectiveness of care. Knowledge of electronic medical record documentation. Qualifications: Current State of Michigan License (unrestricted) as a Licensed Master of Social Work (LMSW), or Limited Licensed Master of Social Work (LLMSW) obtaining full licensure within six months of hire. Master's Degree in Social Work required. Three to five years of clinical experience or medical social work experience preferred. Essential Functions and Responsibilties: Receives referrals for moderate and complex patients through risk stratification, registries and provider referrals. Assesses patients’ mental health, substance abuse and psychosocial needs through standardized assessments. Recommends treatment plans based on evidence based guidelines. Educates patients and families on behavioral health and social barriers. Provides care coordination and follow-up for chronic medical, mental health and substance abuse services across the continuum of care. Follows patients longitudinally to evaluate treatment goals. Advocates for patients and family members while maintaining professional boundaries. Consults with members of the care team on treatment plans and follow-up care. Provides brief therapy for acute and chronic conditions. Participates in process improvement activities to enhance behavioral health services and workflow.