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University of Rochester Sr Social Worker (S) - 222212 in Rochester, New York

Sr Social Worker (S)

Job ID



Strong Memorial Hospital

Full/Part Time


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Full Time 40 hours Grade 055 Psychiatry SMH Social Work


Position Summary:

The Complex Care Center (CCC) provides interdisciplinary care to adults with pediatric onset conditions including developmental disabilities, sickle cell disease, cystic fibrosis, cerebral palsy, among others. Clinical services at the CCC include primary care, dentistry, physical/occupational/respiratory therapies, dietician, and behavioral health. The CCC provides complex and coordinated care through one single point of entry through the coordination and engagement of multiple clinical departments and service lines. The Division encompasses the Complex Care Center's research, training, community service and clinical activities.

Under general direction, but with considerable latitude to exercise independent judgment, serves as Program Manager, Care Management (PMCM) reporting to the Chief of the Division of Transitional Care Medicine. In care management the PMCM will leads the care management programs of the Complex Care Center, supports and integrates into other URMC/AHP care management initiatives that address the needs of adults with pediatric onset conditions, as well as providing direct social work supports for CCC patients. This will include leadership at the regional level with service organizations such as ARCs, Heritage Christian Services, SKIP of NY, Easter Seals, and many other case management/service providers. This person will facilitate local patient recruitment for group visits, research and other center based events. The role will provide direct patient care to our patients with extensive mental health needs and manage a program of care management including NYS Health Home programs, integrated OPWDD care coordination, community outreach workers, and nursing based programming.The Program Manager is responsible for navigating staffing issues such as recruiting, effort management, and professional development. Demonstrates !CARE* values in each of the major responsibilities.NOTE: This document describes typical duties and responsibilities and is not intended to limit management from assigning other work as required.Major Responsibilities


  • Take leadership role in representing the work of the division and CCC to state and regional stakeholder including but not limited to OPWDD (Office for Persons with Developmental Disabilities), FLPPS (Finger Lakes Preferred Provider Systems), and other community based organizations

  • Direct oversight and management of the manager of community care coordination at the CCC to ensure adherence with fiscal and quality assurance benchmarks within those programs. This program includes care management programs like NYS Health Home, OPWDD Care Coordination, and grant based initiatives

  • Collaboration with and ensuring alignment of CCC programs of transition care management, nursing care coordination, mental health coordination, and primary care medical home management.

  • Take leadership role within the CCC to identify opportunities for research and grant based initiatives with other community organizations

  • Provide career development opportunities, monitoring staff performance, and completing employee performance evaluations.

  • Address gaps between population resources and population needs

  • Liaise with the URMC/AHP Care Management Organization and play a leadership role for the CCC in those forums

  • Attend quarterly meetings with the CCC Community Advisory Board, annual or bi-annual presentation to Advisory Board


  • Provides direct medical social work care for patients of the Complex Care Center (CCC) in coordination with other CCC care management resources and community supports

  • Provides direct collaborative care coordination support for those undergoing mental health treatment in cooperation with CCC psychiatrist for revolving panel of 15 patients including documentation and billing requirements for care management billing.

  • Provides comprehensive psychosocial needs assessments of patients of the CCC annually.

  • Supports mental health screening of all patients at the CCC

  • Engages with patients that have accessed inpatient or emergency psychiatric services to support discharge planning and engage following the return to the community to prevent recurrent hospital based care.

  • Works collaboratively with crisis services in the community including Mobile crisis and OPWDD service organizations to provide appropriate interventions and follow up based on needs

  • Provides Crisis Intervention during working hours including safety assessments and planning

  • Participates in interdisciplinary team meetings to coordinate and optimize patient care plans

  • Engages the patient's family or other supports in the assessment and treatment process, and where appropriate provides education, support, and/or treatment to the patient's family/support system.

  • Provides internal and external systems advocacy for patients and families as indicated in care plans.

  • Documents all patient care activities and interventions in the patient's medical record in compliance with division policies

  • Provides back-up clinical services as needed during the absence of program staff of other care managementresources

  • In special circumstances, makes visits to patients' homes or community agencies/schools to implement care plans.

  • Performs other duties as assigned


  • The senior social worker provides education to interprofessional colleagues assigned to the Program (s).

  • Provides and participates in clinician/staff training and education in integrated behavioral health primary care model.

  • The senior social worker may function as a fieldwork instructor for graduate and undergraduate social work students.


  • The senior social worker may participate in the development and/or implementation of social work or interdisciplinary research endeavors, as determined by the social work supervisor in consultation with the Chief of the Division of Transitional Care Medicine


Supervision/Consultation: The senior social worker's professional performance is supervised by a Social Work Division supervisor who is licensed by the State of New York (LMSW, LCSW, or LCSW-R).


The senior social worker is accountable to the Chief of Division of Transitional Care Medicine and to the Manager for Behavioral Health Social Work for the provision of social work services, and adherence to Social Work policies, procedures, and standards of professional conduct. The senior social worker's job performance must conform to the expectation set forth in the position description.


Social work evaluations are conducted annually by the senior social worker's supervisor, with commentary from the Chief of the Division of Transitional Care Medicine. Salary increases and promotional recommendations are subject to guidelines established by the Social Work Division, Strong Memorial Hospital and the University of Rochester.


The senior social worker who occupies this position must have an MSW from an accredited social work graduate program as well as a New York State license (LMSW or LCSW). Prefer 2 years of social work experience. Applicant must be proficient in use of electronic medical records, conducting formal organizational assessment, data collection and storage, and use of software necessary for compiling relevant metrics for reporting and publication.


This position description is reviewed annually by the senior social worker and his/her supervisor. Position review provides opportunity for comment from the Chief of the Division of Transitional Care Medicine and for updating, as needed. Similarly, if a new social worker is hired for the position, a review and update of the position description should occur. Changes in the position description are recommended by the supervisor, in consultation with the Chief of the Division of Transitional Care Medicine. Manager for Behavioral Health Social Work authorizes any position modification.

Reports to: Chief of the Division of Transitional Care Medicine and the Manager for Behavioral Health Social Work

Equipment: Computer, telephone, printer, fax, scanner, copier (multifunction device)


  • Excellent verbal and written communication skills, including the ability to effectively network within and outside the University

  • Ability to access and update medical records

  • Use of software to compile and report on relevant metrics

  • The ability to conduct an organization assessment and develop detailed written proposals

  • Excellent staff management and mentorship skills

  • Strong computer skills, including the ability to use Word, Excel, Access, Adobe, PowerPoint, and other software package

┬┐System Access Requirements:

  • Complex Care Center shared drive

  • Netsmart

  • E Record

  • MyPath

  • How To Apply

All applicants must apply online.

EOE Minorities/Females/Protected Veterans/Disabled