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CMU Medical Education Partners Medical Social Worker in Saginaw, Michigan

The purpose of the Social Worker role is to work with an assigned patient population in an ambulatory/ primary care setting to promote optimal health. In partnership with the primary care practice team, the Social Worker coordinates care for medically complex children and adults, serves as a resource to guide families and patients through disease self-management, ensures access to an array of community services, administers behavioral health screenings and conducts and arranges for more detailed assessments when indicated. He/She serves in an expanded health care role, collaborating with specialists, the health care team, patients and families to facilitate the delivery of quality, efficient, and cost-effective health care.

The services will be provided in accordance with the philosophy, mission, standards, policies, and procedures of the health services ordered by the physician.


  • Plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health. Delivers brief interventions to support necessary lifestyle and behavioral changes. Integrates evidence-based clinical and preventative guidelines, and protocols, in the development of individualized care plans

  • Actively manages a caseload commensurate with experience and the complexity of the individual patients. Provides targeted interventions to avoid hospitalization and emergency room visits. Coordinates care across the continuum and assists patient/families to understand their health care options.

  • Responsible for transition of care (TOC) calls, within 2 business days of discharge, from an acute or semi-acute setting to home. TOC includes medication reconciliation, ensuring PCP or specialist follow-up appointment are arranged, assessing symptoms, teaching warning signs, reviewing discharge instructions, coordination of care, and problem-solving barriers.

  • Works with CMEP leadership to develop and maintain the social service program, drafting supporting policies, procedures, and guidelines for the program. Develops and maintains a thorough knowledge of referral resources throughout the service area.

  • Maintains required documentation for all care management activities, and codes appropriately for services provided.

  • Maintains accurate and timely records including clinical and progress notes according to department policy and codes appropriately for services provided.

  • Develops working relationships with leaders in community resource groups, representing CMU Health at meetings and on various committees that address the social needs of patients such as Council on Aging, Developmental Services, etc.

  • Supports CMEPs commitment to education by occasionally supervising social work students for internships or other educational opportunities.

  • Acts as resource person for other members of the health care team, providing in-service education and consultation in understanding the social and emotional factors related to health problems.

  • Maintains knowledge of the field including Medicare, Medicaid, and other third-party reimbursement sources.

  • Participates in planning and implementing quality improvement activities.

  • Provides positive customer relations in dealing with patients, families, physicians, fellow department employees, other hospital departments, referral resources, service agencies, and others.

  • Adheres to department/hospital policies.


  • Ability to observe, assess, and record symptoms, reactions, and progress.

  • Knowledge of legal and ethical standards for the delivery of medical care.

  • Ability to maintain quality, safety, and/or infection control standards.

  • Knowledge of community medical diagnostic and patient care services in area of medical expertise.

  • Knowledge of current principles, methods and procedures for the delivery of medical evaluation, diagnosis and treatment in area of expertise.

  • Ability to work both independently and in a team environment.

  • Effective verbal and written communication skills.


  • Moderate physical activity. Requires handling of average-weight objects up to 25 pounds or standing and/or walking for more than four (4) hours per day.

  • Work environment involves exposure to potentially dangerous materials and situations that require following extensive safety precautions and may include the use of protective equipment.

  • Will work with blood or blood-borne pathogens and will require OSHA training.

  • Master’s degree in social work from an accredited school of social work is required

  • Current master’s level clinical license with State of Michigan required or able to obtain within 6 months of hire (Licensed or Limited License)

  • Minimum three years of social work experience required with adult medicine and pediatric patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting; five years preferred.

  • Experience as participant in continuous quality improvement preferred.

  • General computer knowledge and capability to use computer required.

ID: 2020-1339

External Company URL: https://cmuhealth.org/physiciancareers