Social Worker Navigator - Grand Rapids, United States - Christian Living Services
Description
TANDEM365 is excited to offer a great opportunity for a Social Worker (LMSW) to advance their career to the next level. This role comes with competitive compensation, flexibility, some remote work options, and the chance to be a crucial part of an interdisciplinary health care team.
Our organization combines a comprehensive medical case management program with a robust community paramedicine initiative that provides quick response and in-home interventions. We focus on delivering innovative services to address healthcare complexities and enhance the lives of our participants.
At TANDEM365, our team of highly skilled nurses, medical social workers, community paramedics, and medical assistants work together to help participants with complex medical needs navigate the healthcare system, achieve their goals, and avoid unnecessary hospitalizations. This approach aims to keep them at home and effectively manage their conditions, offering a patient-centered care model to minimize care gaps and fragmentation.
In this community-centered program, the MSW Navigator conducts assessments in participants' homes or other settings, utilizes innovative interventions to address diverse needs, and excels in person-centered care planning. Responsibilities include coordinating and collaborating to ensure appropriate services are provided across the care continuum.
- Conduct in-home and phone assessments to develop care plans
- Collaborate with mental health providers for care coordination
- Identify social determinants of health needs and implement suitable interventions
- Assist with Advance Care Planning
- Support self-management initiatives
- Engage in challenging, goal-oriented discussions
- Work with the care team to prevent unnecessary hospitalizations
- Facilitate connections to relevant resources
- Demonstrated flexibility, resilience, and adaptability
- Ability to work independently and take initiative
- Strong prioritization and organizational skills
- Team player mindset with excellent collaboration abilities
- Valid MSW licensure in the State of Michigan
- Minimum of 3 years of social work experience
- Previous experience in post-acute older adult care is desirable
- Background in caring for individuals with behavioral health conditions and complex medical issues is a plus
- Familiarity with community-based resources and strong networking capabilities
- MMAP training is advantageous
- Understanding of the Advance Care Planning process
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