3 days per week- Part time About the Department Social Work (MSW) for home based primary care program. This position will conduct home visits and telephonic care management for patients living in the greater Grand Rapids area. Work as part of an interdisciplinary team to help manage the health care of elderly and frail patients who have difficulty leaving their home for appointments. Scope of Work Plans and prioritizes care for individuals and population of clients, focusing on strategies that will promote optimal health within populations. Provides peer support and role modeling related to the development of life skills and health/wellness to individuals and families during home visits, if applicable. Demonstrates expertise, current knowledge in patient care and management of a caseload of clients of varying complexity and seeks to improve patient, family and health systems/community outcomes through the application of educational concepts/skills and preventive care in a managed care environment. + Visit homes to determine client and family needs. Develops prioritized plan to meet needs, and provides services. Follow-up with families, community agencies and volunteers to evaluate effectiveness of services provided and plan for future needs. + Assesses internal and external referrals to identify patient/significant others’ needs, level of intensity, insurance benefits and other patient resources. + Develops plan of care and makes recommendations to PCPs, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum. + Assesses the educational needs of clients, families and members of the health care team and develops and implements appropriate teaching strategies or makes appropriate referrals. + Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner. + Documents patient data, plan, interventions and outcomes according to department guidelines. + Maintains knowledge of current trends and developments in the field by reading appropriate books, journals and other literature, and attending related conferences, seminars, etc. + Ensures that processes and services are continuously monitored for quality, cost effectiveness, and efficiency. Engages in process and quality improvement activities. Makes and implements recommendations to improve operational efficiency and to implement new services for areas of responsibility. How we will care for you, while you care for our patients + Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here (https://careers.corewellhealth.org/us/en/benefits-new) . + On-demand pay program powered by Payactiv + Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! + Optional identity theft protection, home and auto insurance, pet insurance + Traditional and Roth retirement options with service contribution and match savings + Free onsite parking Qualifications + Required Masters Social Worker + 2 years of relevant experience related field Required + License- Master Social Worker (MSW-Master) - State of Michigan Upon Hire required Primary Location SITE - 7751 Byron Center - Byron Center Department Name Home Based Primary Care - CHMG West Employment Type Part time Shift Day (United States of America) Weekly Scheduled Hours 24 Hours of Work 24 Days Worked Variable Weekend Frequency N/A CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.