MSW - CARE TRANSITIONS SOCIAL WORKER

General Responsibilities:  

Under the supervision of the Care Transition Program Supervisor, works within the Care Transitions Program, which is an intervention designed to reduce thirty day re-hospitalizations for at-risk adults. The Care Transitions Social Worker will connect individuals with community resources and medical providers through a person centered process. The Care Transitions Social Worker will meet with potential clients prior to hospital discharge and conduct follow-up visits in the community setting for thirty days. Maintains communication with appropriate hospital and TCOA staff.

Essential Job Functions: (Reasonable accommodations will be provided, if necessary, for individuals with disabilities who can perform the essential job functions.)

1. Provide Bridge Model transitional care services to adults and their caregivers.
2. Conduct comprehensive social work assessments before and after client discharges from the partner hospital(s).
3. Work directly with clients and caregivers to address unmet needs by connecting necessary care providers to each other or to the client/caregiver, exchanging health information in a timely manner and setting up necessary community services before and after discharge using a person-centered approach and care plan.
4. Develop and maintain partnerships with organizations involved in client care. Examples of organizations include, but are not limited to, hospitals, home health care providers, community physicians and clinics, volunteer organizations, faith-based organizations, and local businesses involved in care provision.
5. Document every transition in accordance with agency and program guidelines in the appropriate database.
6. Work with clients in multiple settings, including making home visits.
7. Work with a flexible time schedule.
8. Order and monitor services for client, post discharge.
9. Examples of job functions listed do not include all tasks which may be found in this position. Duties and responsibilities may be added, deleted or modified at any time.

Knowledge, Skills & Abilities:

1. Commitment to the organization’s missions and goals and to represent the Agency in a professional manner.
2. Computer skills sufficient to learn specific departmental software programs.
3. Ability to work independently or as part of a team and maintain confidential information regarding all aspects of client, volunteer, employee and agency information.
4. Ability to communicate effectively and establish good relationships with staff, clients, volunteers and vendors.
5. Cultural competency of the community served; bilingual/bicultural as appropriate to the community.
6. Familiarity with local resources
7. Person-centered, motivational, and empathetic interviewing skills.
8. Must be able to adjust priorities to meet deadlines in a timely manner.
9. Must have excellent verbal, writing, and comprehensive social work assessment skills.
10. Ability to make quick, sound and effective decisions.
11. Working knowledge of budgets, financial resources and accounting principles.
12. Ability to meet department standards with regard to job knowledge, client focus, initiative, productivity, communication, teamwork and attendance.

Requirements:

• A Master’s degree in social work is required.
•  A current Michigan Social Work license in good standing is required.
• A minimum of 2 years experience in healthcare, social services or a related field and clinical experience with older adults and caregivers is required.
• Must possess a current Michigan Driver’s license in good standing (less than 4 points preferred)

Working Conditions:

• The work environment varies. When in the office, safe work practices in regard to office equipment, avoiding trips/falls and fire regulations are required.
• Travel to other sites is required and exposure to unusual elements such as inclement weather, smoke, unpleasant odors, loud noises and extreme temperatures rises
• Physical mobility is required for sitting, walking, standing, bending and lifting/holding/carrying objects of up to 20 pounds. Ability to enter and access information using a computer. Must be able to communicate effectively with clients, co-workers volunteers and vendors in person and over the telephone.

• Sensory requirements include exposure to uniform temperatures, conversational noise levels and everyday office activities.

• Mental requirements include the ability to handle varying levels of stress.

Health Insurance Portability and Accountability Act (HIPAA):

All employees who have access to health information whose confidentiality is protected by the HIPAA Privacy & Security Rule are required by the Rule to receive training so that they have an understanding and knowledge of the Privacy & Security Rule that corresponds to their job duties. Training on the requirements of the HIPAA Privacy & Security Rule and the plan’s health information policies and procedures under the direction of the plan privacy & security officer(s) is a prerequisite for this position. Employees who violate the requirements of the HIPAA Privacy & Security Rule will be subject to discipline up to and including termination.

Reports to: Care Transitions Program Supervisor

Work Location: Tri-County Office on Aging and Sparrow Hospital.

Base work schedule: 8 a.m. - 5 p.m., Monday-Friday (full-time) with a 1 hour lunch. This position will require occasional evening and weekend hours

Applicants must submit a resume, cover letter and Tri-County Office on Aging application by email to hr1@tcoa.org. You may also apply in person at Tri-County Office on Aging, 5303 S. Cedar, Suite 1, Lansing, MI 48911.   Applications for TCOA positions may be found at www.tcoa.org

TCOA is an equal opportunity employer