Ambulatory Care Management Coordinator

Metro Health | Wyoming, MI

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Posted Date 10/08/2019

Ambulatory Care Management Coordinator - Social Work * Days - 40hrs/wk

Requisition #: req1792

Shift: Days

FTE status: 1

On-call: No

Weekends: No

General Summary:

The Ambulatory Care Coordinator – Social Work is a Licensed Master of Social Work (LMSW) leader who assists in the management of the Ambulatory Social Work Care Management team and coordinates the care management services provided to adult and pediatric patients and families in an ambulatory setting. The Ambulatory Care Management Social Work Coordinator performs care coordination, clinical assessments and therapeutic interventions with the goal of optimizing patient’s physical and mental health. The Ambulatory Care Management Social Work Coordinator serves as the mental health specialist and community resource expert. This integral role expands primary care’s scope of practice by focusing on mental health and social needs to ensure the delivery of comprehensive, efficient and quality care.


  • Current State of Michigan License (unrestricted) as a Licensed Master of Social Work (LMSW).
  • Master's Degree in Social Work required.
  • Three to five years of clinical experience or medical social work experience preferred.
  • Demonstrated leadership
  • Previous experience in the Care Management preferred.

Essential functions and Responsibilities:

    1. Assists with scheduling staff based on budgeted FTEs, skill mix, patient needs, and coverage.
    2. Facilitates daily operations of the department.
    3. Manages appropriate staff resources and allocate departmental based activity and budgeted hours in various care areas.
    4. Provides clinical direction, evaluate staff performance, and complete evaluations on time according to schedule.
    5. Performs daily maintenance and payroll processes of time and attendance.
    6. With the oversight of the Manager, assists with departmental budget and demonstrates fiscal responsibility and stewardship.
    1. Functions as a role model, demonstrating expertise in clinical judgment, system navigation, and execution of the social work process within this context.
    2. Receives and acts on referrals for moderate and complex patients through risk stratification, registries and provider referrals
    3. Assesses patients’ mental health and biopsychosocial needs through standardized assessments
    4. Recommends treatment plans based on evidence based guidelines
    5. Educates patients on preventive health, chronic illness and recommended treatments
    6. Provides care coordination and follow-up for chronic medical, mental health and substance abuse services across the continuum of care
    7. Follows patients longitudinally to evaluate treatment goals
    8. Advocates for patients and family while maintaining professional boundaries
    9. Consults with members of the care team throughout the continuum on treatment plans and follow-up care
    10. Provides brief therapy for acute and chronic conditions.
    11. Participates in process improvement activities to enhance behavioral health services and workflow.
    12. Mentors staff in the Ambulatory Social Work Care Management role, promotes team collaboration, and appropriate delegation.
    13. Functions in a direct Social Work Care Management role approximately 50% of the time.
    1. Participates and serves on committees, task forces, and work groups at the department and hospital level as determined by the Manager.
    2. Assists in the development, maintenance and revision of departmental standards, policies, procedures and guidelines.
    3. Demonstrates knowledge and consistently applies departmental policies.
    4. Demonstrates knowledge of professional standards of care.
    5. Supports professional growth and staff development of all departmental employees.
    6. Collaborate effectively with departmental team, departmental leadership, other departments, physicians, and senior leadership.
    7. Manages situations in a high level of autonomy and in an effort to maximize patient and staff safety and minimize risk.
    1. Demonstrates clear and effective communication skills, both written and verbal.
    2. Demonstrates effective conflict resolution skills.
    3. Appropriately utilizes and promotes the use of the chain of command.
    4. Demonstrates and promotes excellent customer service
    5. Demonstrates knowledge of and respect for patients', families', and employees' rights, including confidentiality.
    1. Assist in the planning, implementation, and evaluation of quality management and survey readiness activities.
    2. Actively promotes safety initiatives within department.
    3. Performs audits, as needed, to ensure compliance with social work standards and policy.
    1. Achieves professional development goals as set in previous evaluation or counseling session with Manager.
    2. Independently manages mandatory education and competency requirements.
    3. Demonstrates accountability for own professionalism including appearance, attendance, efficient use of time, attitude, and organization of personal work area.
    4. Exemplifies the Best Practice Standards
    5. Supports change process and mentors others in the change process.
    6. Performs other duties as assigned. These may include but are not limited to: Maintaining a current knowledge base of department processes, protocols and procedures, pursuing self-directed learning and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management.
Job Type
Full time

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