Overview:
Greater Flint Health Coalition is seeking an experienced Social Worker to provide healthcare
focused social work and care coordination services for Community Health Access Program
(CHAP) clients, including but not limited to assessment of issues and barriers to comprehensive
healthcare, education, referrals to counseling/ mental health/substance use treatment, linkage
to community referrals, and follow up to ensure appropriate services are acquired. This position
coordinates needs of clients, acts as a liaison between Mid-Michigan CHAP and participating
medical practices and providers, and consults with the Mid-Michigan CHAP team regarding
social and behavioral health issues. This position works as a member of the interdisciplinary
Mid-Michigan CHAP team collaborating with physicians, physician practices, and community
organizations to provide services to individuals/families that address social determinants of
health to achieve health equity for individuals/families. This position will manage and provide
support to a team of Social Workers and Community Health Workers while serving as an
educator, role model and advocate.
Mid-Michigan CHAP is an innovative and collaborative approach to improve the health
outcomes for clients served while reducing costs. Through these programs, a multi-disciplinary,
community and clinically based team will link families with a medical home (primary care
physician), health behavior, transportation to medical home visits, interpreting services, and
community resources to address social determinants of health. The position will not be
providing direct health care or clinical services but serves as a community-based mechanism to
eliminate barriers and improve coordinated use of services.
Operated via the Greater Flint Health Coalition, the Care Coordination Manager will join our
team based in Flint, Michigan, working in a fast-paced, demanding, but rewarding collaborative
environment. You will have the opportunity to use your social work experience, as well as
clinical and community knowledge, to improve health outcomes and healthcare access for
children.
Primary Responsibilities:
- Train, develop, and manage care coordination staff including Social Workers and
Community Health Workers
- Plan for, direct, and review work of staff
- Identifies and participates in the development of ongoing training and education
required for care coordination staff Effectively manage a medical/healthcare social work caseload and determine
intervention strategies based on the referral type, previous interventions, and
information from the provider(s) and client(s).
- Receive social work referrals and schedule initial office/home visits and/or conduct
phone calls with families to complete assessment, provide education, and connect
families with resources or provide referrals to outside agencies.
- Provide education to clients on appropriate use of all health care services and promote
practice of “medical home-ness.”
- Complete brief patient/family assessments during office/home visits and phone
consultations.
- Interview patients, families, community professionals, and providers as necessary
- Continually conduct office/home visits and/or phone calls as needed based on client
needs and referral options.
- Interpret information gathered during office/home visits/phone calls and identify
patient/family needs and appropriate course of action.
- Provide de-escalation intervention to clients/providers as needed.
- Consistently act as a consultant to case managers, other team members, or outside
agencies upon referral, request, or self-identification of needs.
- Identify appropriate community agencies or resources for patients, families, and
establish referrals and/or empower patient/family to seek necessary help.
- Promote positive decision-making, stress management, and coping skills to patients and
families.
- Serve effectively as a patient/family advocate and supportively allow family members to
express ideas concerning provider care and barriers to comprehensive healthcare.
- Document in the database all client and provider consultations, contacts, attempted
contacts, and client treatment plans and interventions; provide timely and professional
feedback to providers on outcomes of their referrals.
- Provide technical assistance to and serve as a resource for other team members for
questions and information regarding social work and behavioral health issues.
- Maintain positive relationships with outside community agencies and stay updated on
new or existing programs.
- Manage relationships with medical homes regarding client concerns, and may attend
practice staff meetings as appropriate.
- Establish and promote collaborative relationships with team members, providers and
other agency partners.
- Adhere to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
all related legislation to safeguard Protected Health Information (PHI).
- Communicate with health plan staff regarding client concerns as needed.
- Represent social work/behavioral health perspective and/or concerns to Management
Team.
- Other responsibilities as assigned.
Qualifications & Experience Required:
- Bachelor’s Social Worker degree required, Master’s preferred.
- Minimum 2 years related experience.
- Minimum current license for Social Work in the State of Michigan: LBSW, LMSW
preferred.
- Work experience in a health service setting preferred.
- Experience training multi-disciplinary teams preferred.
- Experience conducting in-office and/or home visits preferred.
- Possess the knowledge, skills and experience necessary to provide effective case
management and short-term solution-focused engagement, including basic motivational
Interviewing techniques.
- Valid Michigan driver’s license, automobile insurance and a reliable vehicle.
- Strong working knowledge of families within the community systems, and/or the
Michigan Medicaid system.
- Knowledge/experience of early childhood, the healthcare system, and home visiting
programs strongly desired.
- Excellent communication and interpersonal skills needed to provide effective
collaboration with patients, family, health care team and any other external entity
necessary across the continuum of care.
- Knowledge of local community resources.
- Must be able to work as a part of a team and in a collaborative setting.
- Ability to accept and act upon constructive feedback and verbal or written direction of
work.
- Ability to exercise discretion and independent judgment with respect to matters of
significance, and perform work related to client complaints, disputes, and grievance
resolution.
- Computer skills include a working knowledge of Outlook, Word, Excel, and database
systems.
- Demonstrates self-directed, self-motivated, responsible behavior.
- Able to think independently and make sound judgments.
- Maintains high level of confidentiality and is non-judgmental.
- Demonstrates a high level of cultural competency in the daily performance of duties.
- Informs supervisor of challenges; seeks guidance as needed.
- Supports and cultivates self and fellow team member’s growth and development
- Assumes responsibility of continuing education and improvement to enhance skills.
- Ability to prioritize and manage multiple priorities and projects while meeting deadlines
and expectations.
- Ability to discuss and understand the issues that surround health equity and health care
systems.
- Follows all federal, state, and local laws/regulations and Greater Flint Health Coalition
policies and procedures.
- Considerate, attentive, and punctual.
- Motivated.