Overview

Care Coordination position is on-site 1-2 days a week and remote 3-4 days a week

Join our team in driving a healthier future.

M Health Fairview Clinics was named one of eight "exemplar" integrated behavioral health primary care models across the country. Integrated care is a result of an engaged primary care team and Behavioral Health Clinician providing patient-centered care addressing mental health and substance abuse conditions, health behaviors, stressors, social determinants of health, and ineffective patterns of health care utilization. At M Health Fairview, integrated care is a team based approach to provide patient-centered care. M Health Fairview's integrated behavioral health model was further enriched in 2016, when we began to offer Behavioral Health Home (BHH) services. We are the largest Behavioral Health Home provider in the state of Minnesota, with urban and rural locations. We are pioneering innovative care delivery models to deliver the best care to our patients.

M Health Fairview has an immediate opening for a Social Work Care Coordinator to support M Health Fairview's Wyoming clinic. This position provides a wide range of clinical social work support and interventions supporting our Behavioral Health Home program, to assist patients and families as they transition through an episode of care. This position supports patients and families in coping with the consequences of their illness and health care status.

The position is located at the M Health Fairview Clinic – 5200 Fairview Blvd, Wyoming, MN 55092

Responsibilities Job Description

• As a key member of the Behavioral Health Home team, the Social Work Care Coordinator (SWCC) supports health and wellness for patients with chronic mental health and physical health conditions. BHH is an integrated team based model where the SWCC works closely with the Behavioral Health Clinician, Community Health Worker, and the Primary Care Provider to coordinate care, support care transitions, and improve patient experience, quality of care, and improve health outcomes for our patients.

• Provides a range of clinical social work interventions that include advocacy, casework, counseling, crisis intervention, and care transitions management in assisting patients and families to reach their goals through a combination of face to face and telephonic communication.

• Plans and implements interventions and transition planning based upon psychosocial and risk assessments that are integrated into the patient’s plan of care.

• Initiates/implements transition functions and activities for patients, communicating with patients, families and the health care team to ensure seamless transitions.

• Arranges and coordinates a comprehensive range of community resources; maintains up-to-date knowledge regarding resources and current financial information.

• Effectively communicate transition plans across the continuum of care.

• Partners with inpatient/outpatient care team and community care teams to coordinate care.

Qualifications

Qualifications – Required

• Bachelor’s Degree in Social Work

• MN State License from Board of Social Work

• Knowledgeable of behavioral health conditions

Preferred

• Masters in Social Work

• Three year’s experience in a health care setting

• Exceptional team engagement skills

• Motivational Interviewing Training

• Experience with Epic

• One or more years of acute care experience

EEO Statement

EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status