POSITION DESCRIPTION

POSITION SUMMARY

Social Workers support the Integrated Care Team by reducing social barriers to health and facilitating higher level of care for high risk mental health patients. This includes ensuring that patients have ready access to resources, as well as coordinating connection to community treatment resources. In addition, Social Workers ensure excellent treatment coordination for high risk mental health patients through hands-on clinic coordination, keeping the care delivery team well-informed by bridging communication to and from patients, PCPs, BHCs, and community behavioral health providers when necessary.

KEY RESPONSIBILITIES

• Responds to identified patient social determinants of health (SDoH) through further assessment and connection to community resources. Monitors gaps in referral connection and modifies referral accordingly
• Helps support food bank deliveries, transportation to services, insurance sign-ups, and patient engagement, as needed.
• Supports the psychological well-being of high risk behavioral health patients on an assigned patient caseload. Closely coordinates care with the patient’s medical provider, BHC, and other care team members for monitoring, tracking, and treatment planning
• Manage high risk referral process and monitor follow-up needs, including discharge, ensuring ROI is completed for all patients in caseload for coordinating care with community providers and hospitals
• Provide back up for BHCs for suicide risk assessments and disposition.
• Receive, coordinate, and track referrals for mental health assessment and treatment with community mental health providers
• Update patient registry within eHR for patient monitoring and reporting to care teams, clinical team leads, and Clinical Team Lead
• Function as liaison with mental health and social service partners in the community to coordinate services for patients.
• Works closely with care coordinators though receipt of high risk referrals and update of regular care plan.
• Attends regular supervision meetings with the Social Work Lead and required staff meetings.

JOBS THIS POSITION DIRECTLY SUPERVISES

N/A

POSITION REQUIREMENTS

Education: Bachelor’s Degree in Social Work, Behavioral Health, or related field. Master’s Degree encouraged.

Experience: Patient care and social work experiences required.

Licenses or Certifications: MSW, BSW

Mental Requirements

Physical Requirements

Machines and Equipment Used:

Approximate percentage of time incumbent spends in “on-the-job” travel, excluding commuting to regular work location: Little to no regular travel will be necessary

OTHER REQUIREMENTS

N/A