Trinity Health Social Worker - Team Lead (Outpatient) in Ann Arbor, Michigan


Under the direction of the Program Coordinator and in collaboration with the Medical director the Social Work clinical team lead will provide day to day clinical leadership within the program.

Assists patients and families in coping with problems associated with severe and long-term illnesses. Conducts patient and family interviews, prepares psychosocial assessments, develops treatment plans, provides counseling and crisis intervention, and directs patients to designated community agencies and resources. Provides consultation to patient treatment team members and participates in developing new patient care programs. In various SJMH settings, may provide individual, family, and/or group treatment as part of interdisciplinary treatment plan. Provides quality patient care considering age specific, developmental, cultural, spiritual, diversity, and/or other special needs or circumstances through competent clinical practices.


  • Assists department management in interviewing, orienting, evaluating, training and counseling new staff in an assigned area.
  • Oversees the day-to-day patient care activities of an assigned area by assuring adequate staffing.
  • Schedules, plans and assigns duties of staff to meet patient care requirements, and participates in staff meetings.
  • Monitor timely completion of clinical tasks.
  • Coordinate Social Work monthly meetings to review clinical cases
  • Input to Performance Evaluations for department social workers
  • Make clinical decisions in the absence of or inability to contact attending physician
  • Improve/Implement clinical programming
  • Monitor/Collect clinical data for Quality Improvement initiatives as assigned
  • Monitor/Improve/Implement Patient Safety Standards


  • Functions as a member of the interdisciplinary treatment team.
  • Interviews patients and families to obtain psychosocial data. Evaluates and gather data from the patient, family, outpatient supports and other collateral sources (including the primary care provider) regarding plan of treatment and available resources, and develops an appropriate intervention plan.
  • Provides a variety of direct services and clinical interventions in order to provide continuity of care and to help patients and families resolve socio-emotional problems associated with adjustment to illness, resource needs, mental health problems and a variety of life events and transitions.
  • Coordinates care of identified high-risk patient population across continuum, specifically addressing psychosocial issues. In collaboration with patient, family an primary care provider, develops plan to address and manage issues which influence health care utilization including services for home as well as facilitates hospital-to-hospital transfers, hospice, extended care facility, acute rehabilitation and long term care facility placement.
  • Refers patients to designated community agencies or resources for financial assistance, counseling, mental health and substance abuse follow-up and other support services.
  • Conducts continuity of care planning for assessing needs support services for home as well as facilitates hospital to hospital transfers, hospice, extended care facility, acute rehabilitation and long term care facility placement.
  • Provides ongoing assessment of educational needs of patient/family in collaboration with interdisciplinary staff and develops appropriate interventions and programs in response and maintains good working relationships with community resources.
  • Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist and recognizes when discharge and/or transfer of care is in the best interest of the patient.
  • Advocates, educates, and facilitates resolution of patient rights, ethical and legal issues such as advance directives, end of life decisions, guardianship, etc.
  • Systematically identifies and addresses barriers and fragmentation of care while proactively/collaboratively problem solving to find solutions.
  • Documents social work assessment data and progress notes for each patient including nature of psychosocial concerns, patient and family supports and needs, and intervention plan in accordance with department documentation standards.
  • Provides consultation to other patient treatment team members regarding socio-emotional factors that affect patient’s condition, treatment plan and recovery.
  • Regularly communicates with other departmental and community agency personnel to coordinate social work functions and other services, exchange patient information, and ensure continuity of care.
  • Utilizes pertinent population data to identify trends, potential areas of targeted intervention. Uses metrics to establish measurable goals and monitor outcomes. Uses professional expertise to advance policies and practices that improve access to care, ensures timely follow-up care and supports the delivery of evidence-based clinical management.
  • In conjunction with identified leadership, develops, implements and monitors clinical quality improvement processes within a specific population and/or program.
  • Regularly prepares and presents written reports that track, monitor and measure outcomes of interventions to address patient/population needs and identify and remove barriers.
  • Provides Social Worker leadership in related committees, task forces and work groups with a focus on improved health outcomes for the populations served.
  • Serves as a change-agent and resource to foster adoption of process/service/system improvement initiatives at various points of services. Serves as an advisory role for social policies in community development programs. Understands legal issues that affect treatment, including but not limited to: child custody, divorce laws, child/adult abuse, duty to warn, recipient rights policies and procedures, alternative treatment orders (ATO’s), and the commitment of inpatient hospitalization
  • Maintains knowledge of current trends and developments in the field. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution.
  • Maintains the confidentiality of information acquired pertaining to patient, physicians, employees, and visitors to St. Joseph Mercy Hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places. Follows all HIPAA policies and procedures.
  • Behaves in accordance with the Mission, Vision, and Values of St. Joseph Mercy Health System. Adheres to SJMHS “Performance Standards: Focus on Others”.
  • Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management. Reports all preventable hazards and unsafe practices either including near misses and actual errors to management or using the SJMHS anonymous reporting system (PEERS).

Supplemental Duties and Responsibilities

  1. Assist other Health Center department and staff develop and implement new patient care programs and modify existing programs to meet the needs of patients and families.

  2. Conducts educational and orientation programs for staff, students, and other Health System employees.

  3. Attends and participates in departmental, Health System, and community committees and meetings as necessary.



Master's Degree in Social Work or Psychology from an accredited graduate school.


Current State of Michigan Master’s Degree Social Work License. or Limited License Psychologist. LMSW, LLP or LTD required in Behavioral Health departments.

3-5 years related experience preferred

Behavioral Services Specific:

Minimum of a master’s degree in social work or psychology from an accredited university, with at least five years postgraduate professional, relevant experience. Must be licensed in the State of Michigan and adhere to the code of ethics for his/her area of licensure. Additional training in specialty areas such as chemical dependency, cognitive behavioral therapy, and/or dialectical behavioral therapy is highly desirable.


  1. Interpersonal skills necessary in order to obtain information, provide counseling and interact effectively with patients and families and SJMHS colleagues.

  2. Analytic skills necessary in order to assess patients’ needs develop associated discharge planning and provide sound advice and guidance.

Demonstrates successful and progressive leadership and initiative. Demonstrates consistently high levels of clinical competence with demonstrated ability to provide clinical interventions at the individual, family, group, system and community level.


Job Number: 00111366

Location: Ann Arbor, MI

Organization Name: Saint Joseph Mercy Health System

Facility: SJSEMI - SJMHS Hospital Ann Arbor

Employment Type: Full time

Hours: 40