Community Outreach Social Worker

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Full-Time 40hr/wk Kalamazoo, MI, US

• Assists individuals and groups with personal, social, emotional, and environmental difficulties which predispose illness or interfere with obtaining maximum benefits from medical care. Staff supports providers through an integrated approach to care management and community outreach.
• Develops individualized plans of care with targeted interventions; monitors patients and family responses to the plan of care and adjust as needed.
• Specific focus directed to the Healthcare for the Homeless, Prison Re‑entry and those with Substance Use Disorders. Provides ongoing case management services for those in need of this level of support.

• Performs assessments and provides case management for homeless individuals seeking services at the Family Health Center.
• Coordinates with community agencies to assure that linking, monitoring and coordinating occurs in regard to preventative services for individuals served.
• Reaches out to locate individuals and help schedule their services and appointments both telephonically.
• Communicates with health care team members and agencies to obtain pertinent information to be utilized in evaluating patient needs.
• Provides patients with self‑management tools and support to enhance their ability for self‑care.
• Maintains required documentation for all case management activities.
• Coordinate and provide early intervention services for those exhibiting signs of substance use disorders who may not be amenable to treatment services or who do not meet diagnostic criteria.
• Prepares case histories for use in diagnosis and treatment. Develops intervention and treatment plans which include an evaluation of family support, patient strengths, and level of risks. Make referrals as needed based on the evaluations.
• Work in close collaboration with physicians and other health care personnel in patient evaluation and treatment to further their understanding of significant social and emotional factors underlying patient’s health problem.
• Identifies patients at risk for development for further issues and locates additional Family Health Center or community services best designed to meet their needs.
• Develops comprehensive person‑centered treatment plans in conjunction with patients to meet their social, emotional and behavioral needs. May assist in obtaining authorization for the additional services.
• Helps patient(s) through individual or group sessions to understand, accept, and follow medical recommendations. Follow up on treatment plan in patient’s records.
• Participates as member of multi‑disciplinary team as needed.
• Maintains required case documentation and records delivered services in an accurate and timely manner as required by regulating entities, accreditation organizations, and management.
• Attends required in‑service, department and organizational meetings. Participates in clinical review of cases.
• Reviews current literature on engagement and communication strategies and incorporates best practices into the clinical setting.
• Participates in community collaborative as necessary.

• Displays willingness to make decisions, resolve conflict and delegate work assignments in a timely manner.
• Adapts to change, takes responsibility for own actions to advance team goals.
• Speaks and writes clearly and persuasively, informal and formal presentations.
• Actively participates in meetings and uses listening skills to keep an open mind.
• Solicits input from appropriate stakeholders, explains reasoning for decisions and uses strong interpersonal skills to communicate and influence others.
• Gives recognition to others for results.

• Balances team and individual responsibilities while assessing own strengths and weaknesses.
• Exhibits objectivity and openness to others’ views.
• Welcomes feedback, builds positive team spirit, supports all team members.
• Develops alternative solutions, supports and shares expertise with other team members while building positive…