Medical Social Worker (Long Term Service Support Coordinator)

Location: Kalamazoo, MI
Date Posted: 08-20-2017


Are you a Medical Social Worker that loves being in a team environment who enjoys partnering with the Care Coordinator (RN) to advocate and coordinate the continuum of care for our patients?

Do you love to support your patients in achieving their own goals as described in their care plan and monitor adherence to treatment plans or other disease/chronic condition management programs?

Do you have a strong desire to build close relationships all members of your team and committed to working collaboratively to provide excellent care for patients?

Do you love the idea of a dynamic, field-based position, conducting assessments, coordinating community resources and maintaining care giver care plans?

You will provide a high standard of interaction with our patients to:
  • Perform effective outreach to complete necessary health and social assessment
  • Engage them in the development of an integrated, patient-centered care plan that takes into account needs across the continuum of care
  • Work with a multi-disciplinary care team to develop interventions and changes to the care plan in response to patient’s needs and promotes positive health outcomes.

Essential duties and responsibilities:

  • Perform comprehensive, team-based, and person-centered patient engagement
  • Document patient care plan tasks, goals, and interventions using appropriate mediums (e.g. EMR, historical claims data, outreach logs, etc.) in care coordination record system
  • Identifies caregiver training needs and tracks impact of needs and or training
  • Conduct discharge planning/coordination to ensure all post-discharge LTSS services required are in place Identify the appropriate utilization of resources across the continuum of care
  • Maintain patient/caregiver care plan compliance
  • Participate in quality improvement and evaluation processes
  • Perform and document reassessments, revisions to care plans, and coordinate interdisciplinary care team meetings in accordance with the (health plan) model of care requirements
  • Conduct face to face visits in member’s homes at a minimum of every 90 days, or as scheduled per member needs.
  • Complete all mandatory regulatory and other training required (including but not limited to: compliance training, first tier downstream and related (FWA) entity training, model of care training, etc.
  • Completes multiple comprehensive assessments to determine qualification for additional supports and services.
  • Collaborates with multiple team members (LTSS Coordinator, Care Coordinator, Patient Care Coordinator, and Management)
  • Assists with identification of high-risk members that require a high intensity of care coordination and frequent contact
  • Coordinates community resources depending upon member needs


  • LLMSW, LMSW, LBSW license in the State of Michigan
  • Bachelor’s degree or higher from a CSWE-accredited social work program
  • Minimum of three (3) years clinical experience, HMO /Managed Care setting preferred
  • Care Coordination/Case Management training Knowledge community resources. Knowledge of clinical standards of care. Knowledge of Medicaid/Medicare contracts and benefit systems is preferred.
  • Local travel required for home visits, meetings with families, and other regular meetings are required
  • Willingness to adhere to spending required time in the office at the discretion of Management
  • Professional, flexible, and patient centered “team player” mentality

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
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