Social Worker Maternal Infant Health

Home Health Care Coordinator

Plans and prioritizes care for individuals and populations of clients, focusing on strategies that will promote optimal health within populations. Provides peer support and role modeling related to the development of life skills and health/wellness to individuals and families during home visits, if applicable. Demonstrates expertise, current knowledge in patient care and management of a caseload of clients of varying complexity and seeks to improve patient, family and health systems/community outcomes through the application of educational concepts/skills and preventive care in a managed care environment.

Essential Functions

• Visit homes to determine client and family needs. Perform home health assessment, if applicable, including blood pressure, pulse, BMI and foot checks. Develops prioritized plan to meet needs, and provides services. Follow-up with families, community agencies and volunteers to evaluate effectiveness of services provided and plan for future needs.
• Assesses internal and external referrals to identify patient/significant others' needs, level of intensity, insurance benefits and other patient resources.
• Develops plan of care and makes recommendations to PCPs, specialists and other members of the health care team regarding care management strategies, identifying strategies to maximize continuity of care across the continuum.
• Assesses the educational needs of clients, families and members of the health care team and develops and implements appropriate teaching strategies or makes appropriate referrals.
• Communicates and collaborates with patient/significant others/providers/payers to coordinate services that improve access to appropriate services across the continuum of care and which promotes optimal health in a cost-effective manner.
• Documents patient data, plan, interventions and outcomes according to department guidelines.
• Maintains knowledge of current trends and developments in the field by reading appropriate books, journals and other literature, and attending related conferences, seminars, etc.
• Ensures that processes and services are continuously monitored for quality, cost effectiveness, and efficiency. Engages in process and quality improvement activities. Makes and implements recommendations to improve operational efficiency and to implement new services for areas of responsibility.

Qualifications

Required:

• Associate's Degree nursing, social work, occupational or physical therapy or health related field
• 2 years of relevant experience related field
• LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire Or
• LIC-Physical Therapist - STATE_MI State of Michigan Upon Hire Or
• CRT-Occupational Therapist, Registered (OTR) - NB-COT National Board for Certification in Occupational Therapy Upon Hire Or
• CRT-Speech Language Pathologist - ASHA American Speech-Language-Hearing Association Upon Hire Or
• LIC-Physical Therapist Assistant - STATE_MI State of Michigan Upon Hire Or
• CRT-Occupational Therapy Assistant, Certified (COTA) - NB-COT National Board for Certification in Occupational Therapy Upon Hire Or
• CRT-Registered Dietitian (RD) - CDR Commission on Dietetic Registration Upon Hire Or
• LIC-Master Social Worker (MSW-Master) - STATE_MI State of Michigan Upon Hire Or
• CRT-National Certified Counselor (NCC) - UNKNOWN Unknown Upon Hire Or
• LIC-License Practical Nursing (LPN) - STATE_MI State of Michigan Upon Hire
• CRT-Basic Life Support (BLS) - AHA American Heart Association Healthier Communities and United Lifestyles Only 90 Days Or
• CRT-Basic Life Support (BLS) - ARC American Red Cross Healthier Communities and United Lifestyles Only 90 Days
• LIC-Driver's License - STATE_MI State of Michigan Healthier Communities and United Lifestyles Only Upon Hire

Preferred:

• Bachelor's Degree related field