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Onamia, MN, USA | Hourly | 26.69-43.35 per hour | Full Time

Summary

This position provides high-quality patient care across outpatient service lines. The Social Worker demonstrates strong patient and family assessment skills, plans and implements treatments, facilitates psycho-diagnosis, treatment planning, and discharge planning. The social worker plays a critical role in supporting value-based care initiatives by addressing social determinants of health, integrating behavioral health, and connecting patients to community resources to improve patient outcomes.

Job Duties

The essential functions of this job are identified with an asterisk (*) at the end of the bullet point.

Community Relations and Outreach

• Make regular contacts with referral sources (nursing homes, assisted living, physician offices, community agencies).*

• Attend networking groups and community events to promote awareness of services.*

• Participate in community health fairs, workshops, and public education efforts.

• Maintain up-to-date referral source files and seek new referral opportunities.*

Patient Services and Clinical Care

• Help patients navigate the complex healthcare system, ensuring they understand their rights, assisting with insurance claims, and advocating for their medical needs. Specialize in assisting veterans with healthcare navigation, mental health support, and accessing VA benefits.

• Conduct home visits, coordinating home care services, and offering support to caregivers.

• Support chronic disease management through patient education and resource coordination.*

Substance Abuse Treatment:

• Develop and implement programs for prevention, intervention, and treatment, collaborating with local agencies and support groups.

• Assist in crisis intervention, including behavioral health emergencies.*

• Facilitate advance care planning and completion of directives.*

• Participate in discharge planning and arrange post-hospitalization services.*

• Provider support to expectant and new mothers, connecting them with prenatal classes, breastfeeding assistance, and parenting education.

Behavioral Health and Value-Based Care Integration

• Collaborate with providers on behavioral health screenings and brief interventions like substance abuse, smoking cessation and medication assisted treatment.

• Coordinate care management for complex cases addressing medical and social needs.

• Track social determinants of health data to support clinic quality goals.*

• Facilitate support groups and educational sessions for patients and caregivers on topics like grief, loss, substance abuse, addiction, etc*

• Participate in quality improvement initiatives and report on patient outcomes.

• Cultural Competence: bridge cultural gaps between patients and healthcare providers, ensuring that patients' diverse backgrounds are considered in their care plans.

Communication and Documentation

• Maintain timely, confidential documentation in the electronic medical record (EMR).*

• Communicate effectively with physicians, nursing staff, and community agencies.*

• Prioritize assignments and meet required deadlines.

• Assist with marketing and internal communication efforts as needed.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. Employee will comply with all Mille Lacs Health System (MLHS) policies, including safety policies, procedures, and rules. All will be expected to report unsafe conditions to a member of management.

Required Education and Experience

• Bachelor's degree in Social Work or related field required; Master's degree preferred.

• Licensed Social Worker (LSW) in Minnesota required.

• Experience in outpatient clinics, community health, or behavioral health settings preferred.

• Strong computer skills (Outlook, Excel, EMR systems).

Preferred Education and Experience

• 3-5 years experience in healthcare social work, behavioral health, or community health. Knowledge of value-based care models, chronic care management, and telehealth delivery.

• CPR certification and de-escalation training required (or within 90 days of hire).

Additional Eligibility Qualifications

• Strong organizational and time management skills.

• Proficiency in EMR systems and general computer skills.

• Excellent communication and interpersonal skills to work with diverse patient populations and healthcare professionals.

• Ability to multitask and work efficiently in a fast-paced clinic environment.

• Basic knowledge of medical terminology and clinic procedures.

Position Type/Expected Hours of Work

Monday through Friday day hours. Occasional holidays and work during inclement weather may be required. This position may require long hours depending upon patient need.

Supervisory Responsibility

Provides work direction in coordination with the Clinic Director.