Licensed Social Worker

The Licensed Social Worker works within the interdisciplinary care team as part of the Care at Home Solutions program. As an independently licensed clinician, the Licensed Social Worker partners closely with the Medical Director, Advanced Practice Provider (APP), Registered Nurse (RN), Pharmacist, Community Health Worker (CHW), and Care Navigators to address behavioral health needs, improve psychosocial well-being, and support patients in achieving their health goals. The Licensed Social Worker conducts comprehensive behavioral health assessments, provides evidence-based counseling and brief interventions, develops individualized care plans, facilitates crisis intervention as appropriate, and connects patients with community-based behavioral health and social support resources. The Licensed Social Worker holds an active LCSW CA license or equivalent.  

FLSA Status 

Exempt

Salary Range 

$75,000- $96,000

Reports To 

Director, Care at Home Solutions

Direct Reports 

None

Location 

Hybrid; LA Office

Travel 

Up to 50%

Work Type 

Full-Time

Schedule 

Standard business hours; flexibility based on patient and program needs

Duties and Responsibilities (including but not limited to) 

• Assess identified patients to determine appropriateness for management early in their disease process and at any time during the continuum of care. 
• Complete a comprehensive assessment to identify patient risk and develop a care plan utilizing expertise and judgement to evaluate needs for alternative services as needed. 
• Assess members’ Social Determinants of Health, such as housing, food, transportation, and safety in the home. 
• Work collaboratively with APPs, physicians and community resources including pharmacists, nurses, registered dieticians, and other disciplines to address patient needs as identified in assessments. 
• Assess and screen members for behavioral health concerns (depression / substance abuse) utilizing screening tools, including the PHQ2 and 9 Depression screenings, and ensure they are receiving appropriate behavioral health interventions. 
• Facilitate any necessary follow-up or referrals for behavioral health needs with local behavioral health providers. 
• Develop, facilitate, and communicate a plan of care in partnership with the member, family (or designated representatives), providers, and multidisciplinary care team to assess the options of care including use of benefits and community resources. 
• Update care plan to include progress towards achieving established goals and self-management activities. 
• Coordinate necessary referrals and authorizations pertinent to patient care and well-being. 
• Utilize developed systems, processes, and initiatives to engage patients in relevant social activities necessary to promote wellness and care at the right place and time. 
• Facilitate member adoption of strategies to promote physician recommended behavior changes. 
• Identify and utilize cultural and community resources and align with the patient’s cultural preferences as much as possible. 
• Facilitate the information flow between health representatives and the care team. 
• Coordinate care and communicate with multiple providers, internal and external to the practice. 
• Act as a resource for both clinical and non-clinical staff [i.e., care coordinators, community health works, APPs]. 
• Attend required training and collaboration sessions [i.e., learning sessions/ practice team meetings] as scheduled. 
• Provide and facilitate open communication regarding patient status, with physicians and Care at Home Solutions team. 
• Other job-related duties as assigned. 

Qualifications or Education, Training and Experience 

• Valid and current LCSW, LMHT, LPCC, LMFT, LCADAC, LICSW, or LMSW CA licensure