At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. Job Description Summary Provides care coordination for specific population with severe and persistent Mental Illness (SPMI) and SPMI with chronic health conditions for residents of Mahoning County. Navigates patients to linkage to treatment/care. Works with those who are indigent to seek health care coverage while hospitalized. Navigates inpatient probate cases with the probate court. Builds relationships with community behavioral health partners. Advocates, educates, coaches and provides strength-based resources for patients and families. Assists in development and implementation of interdisciplinary treatment plans, coordinating logistics for plan adherence, reminders, transportation, etc. Works with community partners in the development of community plans for difficult patients who frequent the emergency room or are noncompliant with care. Actively participates in the process for operational and quality improvements. Essential Functions Provide coordinated care for specific population by guiding patients and families, as appropriate, through the healthcare system, i.e. continuum of care by assisting with access and follow up in community that is effective, safe, timely and complete. Develop effective working relationships with Mahoning County providers, i.e. physicians, nurse practioners, community based agencies and coalitions, as well as other community resources to ensure best practices for partied experience, length of stay/avoidable days reduction, readmission reeducation, as well as reduction of patient/family use of Emergency Department. Provide advocacy, education, coaching and strength-based supportive resources for patients and families. Implements delegated portions of interdisciplinary treatment plans, coordinating logistics for plan adherence, reminders, transportation, etc. Documents and monitor compliance with delegated portions of treatment plans, including adherence, barriers encountered, resources accessed, successes and outcomes. Actively participate in the process for operational and quality improvement. Employment Qualifications Required Masters degree in Social Work Preferred Graduate Degree in Social Work , Psychology, or Counseling Licensure/Certification Required Ohio Licensed Social Worker- LSW Preferred Ohio Licensed Independent Social Worker- LISW Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more *Benefits offerings vary according to employment status All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com . If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com