Social Worker- LCSW & Bilingual

We’re unique. You should be, too.

We’re changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The LCSW/Behavioral Health Specialist assists, coordinates and manages the needs of the Behavioral Health patients who are hospitalized by maintaining the Behavioral Health High Priority Patient registry (BH-HPP). The LCSW will adhere to strict departmental goals/objectives, standards of performance, quality patient care compliance, and policies and procedures. LCSWs must be compliant with their state mandatory laws of LCSW licensure renewal by participating and receiving their continuing education hours yearly.

• Conducts timely and appropriate assessment, diagnosis, treatment planning and treatment intervention of patients.
• Including patients who have been readmitted to the hospital within 30 days and/or are at high risk for readmission after discharge from the hospital.
• Identifies and Implement Appropriate Community Resources for the patient.
• Assess the patients for behavioral, psychosocial, financial, family issues, palliative care/end of life issues, home safety, etc. that contributed to the hospitalization and/or could contribute to future hospitalizations.
• Dialogue with general medical providers (PCPs) in order to educate them concerning behavioral health disorders and treatment options available for the patients.
• LCSWs will assist with obtaining community resources and refer patients to the appropriate outside agencies e.g., Medicaid, meals, medications, housing, etc.
• Identifies, manages and coordinates appropriate treatment planning and interventions for patients on the HPP Behavioral Health Registry.
• LCSWs will manage complex behavioral health patient issues by providing casework, utilization management and discharge planning services to promote the highest level of patient functioning as they transition back to a community setting from the hospital.
• Serves as a Behavioral Health linkage between PCPs and patients to improve coordination of services and information flow.
• Provides self-management support and ongoing phone contact with patients.
• Coordinates, reviews and maintains daily logs for reporting purposes and for weekly review.
• Maintains Communication with Other Healthcare Team Members by attending appropriate meetings.
• Provides clinical consultation in an integrated health care environment regarding behavioral health dx and needs family interactions, socio-cultural determinants and community resources.
• Timely and Accurate Documentation.
• Maintains timely, accurate, thorough and appropriate documentation/reports per Jen Care policies and procedures. Assure documentation meets billing guidelines.
• Maintains LCSW State Licensure yearly requirements. Attend behavioral health training seminars to maintain current state LCSW License.

• Knowledge of counseling theories, therapies and techniques, as used in individual, family and group treatment, as well as principles of social welfare are required.
• Knowledge of evidence based behavioral health methods and techniques used in individual, family and group therapy as related to mental health and/or substance abuse issues in a primary care setting.
• Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging and older adulthood.
• Proficiency in assessing for behavioral health challenges in frail, high-risk older adults.
• Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning with patients and/or their family systems.
• Ethical practice behavior consistent with Jen Care policies and professional standards.
• Skill in communication with and psychosocial support of patients with cognitive impairment.
• Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients.
• Appropriate utilization of community-based resources
• Demonstrat…