Job Description

LICENSED CLINICAL SOCIAL WORKER (LCSW)

Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as lengthy delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It is no wonder 98% of patients report being fully satisfied with Upward Health!

Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission. Or you could join us and experience it all for yourself.

Why Is This Role Critical?

The primary role of the Licensed Clinical Social Worker (LCSW) is to assess the psychosocial needs of patients and provide focused care delivery to address barriers that impact a patients physical and emotional well-being. The LCSW is an active member of the Interdisciplinary Care Team (IDT).

KEY RESPONSIBILITIES:

• Experience with behavioral interventions techniques such as: non-judgmental listening, Motivational Interviewing (MI), trauma-based care, and person first thinking.
• Assess patients’ psychosocial concerns and the impact on their current medical status.
• Develop collaborative care plan goals with the patient, IDT members, Care Team Pod, and their family/caregiver.
• Assess and document current advance care directive status and ongoing efforts to reconcile patient/caregiver misaligned goals with current clinical status.
• Connect patient and/or their family/caregiver to appropriate community resources and supports.
• Collaborate on and support plan of care as determined by the physician and Care Team Pod
• Perform initial assessment and periodic re-evaluation of the patient and adjustments in the patient’s treatment plan.
• Provide treatment to patients per protocols, policies, and clinical practice guidelines.
• Facilitate transitions of care for assigned patients per Upward Health policy, coordinate care across the continuum of care.
• Identify innovative actions to meet the needs of the patient from both the health care and psychosocial /socioeconomic dimensions of care as well as acting for provision of services to meet those needs.
• Make care recommendations of the multidisciplinary care team, the patient, family, and caregiver.
• Initiate and maintain ongoing communications with clinicians involved in member care, especially the PCP and Psychiatrist.
• Provide short-term, risk-focused care management.
• Utilize motivational interviewing and other evidenced based techniques to elicit behavior change.
• Promote patient self-management and right to self-determination.
• Intervene in crisis situations when needed.
• Assess Social Determinants of Health and collaborate with team for appropriate referral.
• Enhance and support connectivity between patients and members of the interdisciplinary team.
• Navigate community resources and develop partnerships to improve access to care and ease of systems navigation.
• Identify and report any quality-of-care issues or concerns.
• Ensure strict compliance with federal and state regulations and company policies, procedures, and processes. 
• Attend departmental meetings.
• Perform other duties as assigned.
• Ability to go deep in the community with knowledge of local and state resources to support patient’s needs.
• Excellent written, computer, and oral communication skills – will proactively and thoroughly communicate with other members of the team. 
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MINIMUM QUALIFICATIONS:

• Meet all state certification and licensing requirements.
• Three (3) years of social work experience (internship not included), with 2 years of social work experience in a healthcare setting (physician’s office, PCMH, hospital, clinic, home care or nursing home setting)
• Working knowledge of Medicaid and Medicare, and managed care organizations
• Excellent communication skills and knowledge of navigating community resources.
• Licensed Clinical Social Worker license
• Possession of a valid state driver’s license and access to an automobile
• Experience in delivering home care or field case management is preferred.

Upward Health is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position's responsibilities.

 

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