Social Worker II

Requisition ID
Employment Type
Full Time
Case Management - Population Health
Hours / Pay Period
Standard Hours
Monday - Friday (8:00 AM - 5:00 PM)
Facility / Process Level : Name
MercyOne Des Moines Medical Center


Mission Statement:

MercyOne serves with fidelity to the Gospel as a compassionate healing ministry of Jesus Christ to transform the health of our communities.


MercyOne Vision Statement:

MercyOne will set the standard for a personalized and radically convenient system of health services.


MercyOne Cultural Beliefs:



I benefit from and strengthen MercyOne.


Personalize Care

Your experience.  My responsibility.


Own It!

I own my actions to deliver our key results.


Improve Daily

I make improvements every day for those we serve including each other.



I imagine and embrace bold new ideas to revolutionize health.




Job Summary:


The LISW/LMSW Ambulatory Social Worker functions as a member of the PHSO’s interdisciplinary care management team and provides care coordination services to Population Health patients residing in the community setting. This includes managing a panel of high-acuity patients with a primary diagnosis of a serious mental illness or substance use disorder, supporting transitions of care across the care continuum, and arranging wrap around services.  Understands and complies with PHSO standard work flows upholding accreditation level standards.


Essential Position Expectations:

  • Manages transitions in care following hospital discharges, emergency department use and post-acute stays where mental illness was a primary reason for the admission or visit
  • Leads care coordination services for patients with a serious mental illness or substance use disorder as primary chronic conditions.
    • Provides at least a monthly engagement conducted either by phone, virtually or in person
    • Completes routine assessments of mental, social  and functional needs
    • Develops, implements, and updates patient care plans
    • Facilitates advance care planning discussions and the completion of advance directives for patients ≥ 18 years of age
  • Applies motivational interviewing to strengthen the patient’s own motivation for change and movement towards health behavior goals
  • Identifies, develops and maintains good working relationships with community resources.
  • Refers patients to appropriate community resources for financial assistance, counseling, mental health and substance abuse follow-up and other support services.
  • Arranges home care, hospice services, palliative care or DME services to assist patient in achieving a safe, optimal continuing care plan.
  • Provides ongoing assessment of educational needs of patient/family in collaboration with interdisciplinary staff and develops appropriate interventions and programs in response. Demonstrates ability to make appropriate and useful changes in the patient’s treatment plan when problems persist.
  • Manages transitions in level of care (e.g. transitions from home to a nursing facility)
  • Facilitates family meetings (e.g. level of care changes, care-giver support)
  • Supports patients in creating safety plans
  • Responds to patient’s in crisis
  • Accepts direct referrals from care management team and providers
  • Performs home visits as needed
  • Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day.
  • Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care and patient experience.
  • Upholds and supports PHSO standard workflows and procedures at accreditation level quality.



Education:  Master of Social Work degree from a Council on Social Work Education accredited institution.


Experience:  Minimum of 2 years social work experience. Experience in the health care setting preferred.


Certifications & Licenses:  Iowa state licensure as a Masters of Social Work or Independent Social Worker


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