Social Worker / LTSS Supports Coordinator

Req No.
Regular Full-Time


 Concerto delivers comprehensive care to Medicare, Medicaid, and complex-needs patients. For over a decade, we have provided extraordinary outcomes for thousands of people in these underserved groups.
The Concerto name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. It’s about the harmony of a patient’s care, health, and dignity.
We are looking for an experienced Social Worker (LASW/LICSW/LSWAA/LSWAIC)to join our care coordination department. This dynamic clinical role offers a qualified candidate the opportunity to serve as a key team member in patient care and positively impact the lives of our patients. As Social Worker (LASW/LICSW/LSWAA/LSWAIC) one will be a key participant in coordinating the patient care process, teaming with clinical professionals to address patient concerns as well as to assess clinical risk.  The Social Worker Care Coordinator will assume the role of primary point of contact for the patients’ health related needs by facilitating timely access to care, and educating patients and their families on improving overall health.


The role also includes developing a plan to ensure each patient’s care is delivered in the manner that is most comfortable for them.  The Social Worker (LCSW/MSW) Care Coordinator is expected to build strong relationships with patients in order ensure their needs and wishes are met. This is a unique opportunity to give back to the underserved local neighborhood with a mission-driven organization dedicated to patient centered compassionate care!


  • Identifies patient goals and barriers to those goals; addresses these issues with the patient and their surrogate decision makers.
  • Develops care plans to address patient issues.
  • Arranges and participates in interdisciplinary care team meetings.
  • Assists with identification of high risk members and disease specific issues that require a high intensity of care coordination and frequent contact
  • Performs outbound calls to patients as needed
  • Coordinates specialty and diagnostic services for patients as needed
  • Coordinates community resources depending upon member needs
  • Identifies caregiver training needs and directs caregiver to training resources as needed
  • Assists with discharge planning and coordination as needed to ensure all post-discharge services required are in place and patient has scheduled post-discharge appointment
  • Provides assistance to identify the appropriate utilization of resources across the continuum of care
  • Maintains patient/caregiver care plan compliance reporting.  Submits reports to interdisciplinary care team weekly.
  • Participates in quality improvement and evaluation processes
  • Coordinates and directs the retrieval of diagnostic results from specialty referrals back to the clinic
  • Works with the Pharmacy Benefit Management and other community pharmacies to help coordinate medication accessibility and medication refills.
  • Demonstrates the ability to triage and apply critical thinking skills
  • Demonstrates the ability to work in a fast paced environment; as well as the ability to perform multiple concurrent tasks with minimal supervision and meets deadlines. 
  • Demonstrates the ability to communicate effectively in writing and verbally


  • LASW/LICSW/LSWAA/LSWAIC license in the State of Michigan.
  • Master’s degree or higher from a CSWE-accredited social work program.
  • Minimum of three (3) years clinical experience, HMO/IPA/Managed Care setting preferred
  • Care Coordination/ Case Management training and/or certification Knowledge community resources. Knowledge of clinical standards of care. Knowledge of Medicaid/Medicare contracts and benefit systems is preferred.
  • Local travel (30%) required for home visits, meetings with families, and other regularly meetings as well as occasional out of town travel are required. Knowledge of CPT, ICD-9 and HCPC codes.
  • Professional, flexible, and patient centered “team player” mentality


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