Community Social Worker

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.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• 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 JenCare 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, SKILLS AND ABILITIES:

• 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 JenCare 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
• Demonstrated ability to effectively and sensitively provide care to people from different cultural groups.
• Proficiency in written communication: documentation is clear, concise, and accurate, provides meaningful communication and is consistent with JenCare policy and regulatory requirements.
• Teamwork skills in care coordination with patients, family systems, JenCare staff and external providers.
• Excellent interpersonal, communication and critical thinking skills are required.

EDUCATION AND EXPERIENCE CRITERIA:

• CSW required.
• Bachelor degree required.
• Minimum of two (2) years of experience in working with behavioral health clients providing direct evidence based assessment, diagnosis formulation, treatment planning, treatment intervention and education to patients and/or family members.
• Ability to work autonomously is required.
• Registration in State may be required if applicable.

#deliverthedifference

KNOWLEDGE, SKILLS AND ABILITIES:

• Keen business acuity and acumen
• Full knowledge and understanding of general Social Worker functions, practices, processes, procedures and techniques
• Knowledge of social services documentation procedures and standards
• Knowledge of community health services and social services support agencies and networks
• Knowledge of normative changes (e.g., sensory, cognitive, psychosocial) associated with aging for high-risk patients
• Knowledge of advance care planning and palliative care, and related skill in addressing advance care planning
• Ethical practice behavior consistent with ChenMed policies and professional standard
• Skill in psychosocial interventions with challenged caregivers/family systems of high-risk patients
• Appropriate utilization of community-based resources
• Teamwork skills in care coordination with patients, family systems, staff, and external providers
• Ability to work autonomously is required
• Ability to monitor, assess and record patients' progress and adjust accordingly
• Ability to communicate technical information to non-technical personnel, and with patients and/or their family systems
• Strong interpersonal, communication and critical thinking skills and the ability to work effectively with a wide range of constituencies in a diverse community
• Demonstrated ability to provide care effectively and sensitively to people from different cultural groups
• Ability to create a collaborative relationship to maximize the patient's/family's ability to make informed decisions
• Proficiency in written communication: documentation is clear, concise, accurate, provides meaningful communication and is consistent with company policy and regulatory requirements
• Proficiency in technology, including the utilization of Electronic Medical Record platforms for care coordination
• Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software
• Ability and willingness to travel locally, regionally and nationwide up to 30% of the time
• Spoken and written fluency in English
• This job requires use and exercise of independent judgment

EDUCATION AND EXPERIENCE CRITERIA:

• BS degree in Social Work required
• Master's Degree of Social Work (MSW) preferred
• A minimum of 2 years' work experience in social work, case management, and/or discharge planning experience required
• A minimum of 2 years' experience in a primary care setting preferred
• State Licensure at a Master's Level is preferred but may be required (dependent on state)
• If applicable, incumbent must be compliant with the mandatory laws of state licensure at the Master's level.

We're ChenMed and we're transforming healthcare for seniors and changing America's healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. We're growing rapidly as we seek to rescue more and more seniors from inadequate health care.

ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in people's lives every single day.

Current Employee apply HERE

Current Contingent Worker please see job aid HERE to apply

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