Overview

is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered out of Troy, Michigan, operates home-based primary care practices in 14 states. employs more than 200+ primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model.

Our Mission– To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care.

Our Shared Vision– Every patient deserves access to quality healthcare.

Our Values– The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other.

Why You Should Want to Work with Us

- Quarterly Bonuses – up to $5000 per year!
- Health, Dental, Vision, Disability & Life Insurance, and much more
- 401K Retirement Plan (with company match)
- Tuition, Professional License and Certification Reimbursement
- Paid Time Off, Holidays and Volunteer Time
- Paid Orientation and Training
- Day Time Hours (no holidays/weekends)
- Established in 11 states
- Largest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today!

More details about the benefits we offer can be found at .

Responsibilities

The Clinical Social Worker is an integral member of the care team and contributes to the care coordination for patients with multiple social stressors and/or behavioral health concerns. The Clinical Social Worker utilizes screening criteria for the coordination of quality health care services, reduction of service fragmentation, enhancement of quality of life, and the appropriate use of healthcare and community resources.

Essential Duties and Responsibilities

• Manage a caseload of high-risk socially complex patients
• Conduct face to face and telephonic psychosocial assessments with the patient and/or the caregiver
• Investigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needs
• Provide short-term counseling services as needed
• Coordinate services to ensure the patient/family understands a treatment plan
• Work as part of a collaborative care team to achieve optimal quality and patient experience outcomes, including being an active member in High-Risk Huddles
• Provide outreach to community-based services to support the patient’s ability to age at home
• Develop and implement shared goals of care with the patient and family
• Work with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independence

In this role you may work with. . .

• Providers
• Support staff
• Care Team
• Patients
• Patient Families
• Caregivers
• Facilities
• 3rd party entities
• External Providers
• Community Resources

Qualifications

Required Knowledge, Skills and Experience

• Master’s degree in social work
• Must be licensed as an LCSW or LISW (depending upon state)
• Must maintain a valid driver’s license and good driving record
• The ability to use sound clinical judgment and communicate clearly in both written and verbal formats
• Above average computer skills
• Ability to be self-directed and able to communicate effectively with professional staff across many disciplines and programs
• Must have the ability to plan time effectively, balance multiple tasks, work within stringent time frames, resolve problems, identify patient service trends, determine system improvements, and implement change
• Ability to share expertise with others and demonstrates an understanding of the need to foster performance improvement while achieving patient satisfaction and efficiency

Preferred Knowledge, Skills and Experience

• Experience in Care Management in community-based setting or equivalent
• Experience working with the chronic, complex and/or behavioral health population

Pay Transparency

Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.