Pop Health Social Worker LICSW

The Population Health Clinical Social Worker assists in the integration of the behavioral health and social support to Population Health initiatives in the Newton-Wellesley system.

Consistent with a team-based care model, the Population Health Clinical Social Worker collaborates with all members of the primary care interdisciplinary team to plan and implement optimal and efficient care for medically and psychosocially complex patients. This includes direct provision and/or assistance in the provision of psychosocial and overall mental health services for designated patients and their families in the primary care setting.

This position requires a broad-based knowledge of mental health conditions, psychosocial issues and chronic diseases which impact health. Experience should include crisis management and brief supportive and transitional counseling and coaching. Knowledge of the spectrum of health care services across the continuum, available community resources, and insurance benefit design and reimbursement methods are important components of the role.

The Population Health Clinical Social Worker demonstrates prudent clinical judgment based on established professional standards and guidelines, effective problem- solving skills, critical thinking, and strong organizational and interpersonal skills.

MAJOR DUTIES AND RESPONSIBILITIES:

1. Utilizes evidenced based practice and national standards to optimize the mental health of the high-risk medical and psychiatric population and to maintain these patients in the community, avoiding hospitalization when appropriate. Consults as needed with clinical team including nurse case manager, behavioral health lead, community health worker and practice clinicians.

2. Supports the implementation and ongoing integration of behavioral health and social services in primary practices with a focus on population health and value-based care.

3. Upon referral, assesses a patient for psychiatric history, emotional issues, coping style, understanding of illness and any adjustment or compliance issues, barriers to care, cultural issues, abuse/neglect, and domestic violence issues. As appropriate, works with members of the care team in planning and engagement.

4. Provides mandated assessments when abuse/neglect is suspected (child, disabled adult, elder) and safety assessment when domestic violence is reported. Files reports as indicated.

5. May employ a range of time limited, focused, clinical interventions including care coordination and brief counseling. Provides caregiver/family counseling and/or support to promote family cohesiveness to provide care to the patient and prepare families for end of life.

6. Coordinates family/team meetings as needed.

7. Advocates on behalf of patients and families to gain access to services and resources. Refers patients to other providers as necessary.

8. Maintains appropriate care coordination notes in Epic medical record including Acute Admit assessments, High Risk Assessments, Post discharge assessments and encounter notes as related to the types of care/support patient is requiring.

9. Presents and/or discusses clinical work in formal and informal case reviews as required.

10. Maintains confidentiality and complies with the NASW Code of Ethics according to professional and department standards.

11. Performs other duties as required.

1. LICSW, LCSW, LMHC

2. Minimum of 3-5 years' experience in medical social work, community mental health and/or geriatric psychiatry.

3. Clinical, consultation and care management skills including but not limited to:

* Motivational interviewing and coaching

* Behavioral activation

* Depression and anxiety management

* Addiction and substance abuse

* Management of patients with complex medical conditions

4. Experience working with a variety of community agencies and resources.

5. Ability to work effectively in a complex fast paced medical environment and multiple practice locations.

SKILLS/ABILITIES/COMPETENCIES REQUIRED

* Strong organizational skills with an ability to set priorities.

* Excellent oral and written communication skills.

* Critical thinking and problem-solving abilities.

* Ability to adapt to program evolution and shifts in prioritization.

* Ability to work independently as well as function effectively within a team-based model of care.

WORKING CONDITIONS

* This is a hybrid role, partially remote with an on-site practice-based component. It may require travel to other community settings.

* Monday through Friday generally 8 a.m. to 4:30 p.m. with flexibility to accommodate as needed.

The above statement reflects the general duties considered necessary to describe the principal functions of the job and are not considered a detailed description of work requirements inherent in the position.

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Newton-Wellesley Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.