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Social Work Navigator
4 months ago
**Social Work Navigator (MSW) - Kent County**
TANDEM365 has a unique opportunity for a Social Worker (MSW) to take their career to the next level. This full-time position offers competitive pay, flexibility, some remote work and the opportunity to work as an essential part of an interdisciplinary healthcare team. The territory for this position is Kent County.
**Why Join TANDEM365?**
We are a complex medical case management program coupled with a robust community paramedicine program that offers rapid response and in-home interventions. Our unique population health model exists to provide innovative services and challenge the complexities of healthcare, so the lives of our participants are enriched and transformed.
At TANDEM365, we utilize highly skilled nurses, medical social workers, community paramedics and medical assistants to assist our participants with complex medical needs navigate the health care system, support their goals and prevent unnecessary hospital utilization. Our services help them remain in their homes and manage their conditions more effectively. Our model provides a patient-centered method of care delivery to reduce gaps in care and prevent fragmentation.
**What Will You Do?**
In this community-based program, the Social Work Navigator performs assessments in our participant’s homes or other settings, uses innovative interventions to balance a variety of needs and is skilled in person-centered care planning. Duties include coordinating and collaborating to facilitate and monitor appropriate services across the continuum of care.
**Responsibilities**
- Both in-home and phone assessments to formulate plan of care
- Coordination of care with mental health providers
- Assessing social determinant of health needs and implementing appropriate interventions
- Advance Care Planning
- Working to transition our participants to hospice at the appropriate time
- Empowering self-management
- Conducting challenging goal focused conversations
- Working with the care team to prevent address unnecessary hospitalizations
- Resource connection
**Skills to be Successful**
- Flexibility, resiliency, and adaptability
- Self-directed and autonomous
- Ability to prioritize
- Skilled at initiating and having challenging conversations
- Organized
- Team player mentality
**Education and Experience**
- MSW licensure in the State of Michigan
- At least 3 years of social work experience
- Post-acute older adult care preferred
- Experience caring for individuals with behavioral health conditions in addition to complex and chronic medical conditions preferred
- Knowledge of community-based resources and strong networking skills
- MMAP training is highly valued
- Understanding of Advance Care Planning process
