Position Summary: Responsible for counseling and assisting patients while adhering to diabetes treatment plans. Screens patients to evaluate treatment needs, provides referrals for health and social services, and monitors patients’ progress on treatment plans. 

Critical Tasks: 

Assists patients with diabetes in reaching their wellness goals by providing case management services. Conducts brief screenings and counseling sessions to evaluate the needs of patients.Assists patients in accessing health and wellness resources aligned to their treatment plan. Provides referrals and advocates for patient access of health and social services.Maintains working knowledge of relevant referral sources and programs to serve patients’ treatment needs. Monitors patients’ progress with treatment plans in accordance to the Diabetes Standards of Care and in alignment with best practices in case management. Maintains relationships with patients by scheduling recurring phone and in-person meetings to discuss treatment plans, available services, and overall well-being.Maintains up-to-date documentation of patient communications, office and home visits, and consultations with medical staff to ensure compliances with program policies and procedures.Applies medical, social, and cultural understanding to individualize treatment plans and adapt plans as needed. Coordinates multiple cases and oversees fulfillment of wellness services. Communicates treatment plans and progress with patients and patients’ families. Collaborates with peers and department leaders to evaluate program standards, policies, and procedures and recommends changes based on evolving patient needs. Performs other job-related activities as requested.

Required Qualifications: 

Master’s degree in Social Work or a closely related field required.2 years of experience in Counseling, Social Work, or a similar role required.Arizona state licensure (LMSW or LPC) preferred.Current and continuing CPR and First Aide Training and Certifications.State of AZ Driver’s License with no significant violations during the last 5 years.Demonstrates ability to relate to diverse cultures and specifically the Gila River Community and/or other Native American cultures and community health services.