Title: LCSW

Duration: Permanent

Pay: $75-100K

Must Haves

• Master’s Degree in Social Work
• Must be a Licensed Clinical Social Worker in the state of Oregon
• 6 months’ as a LCSW
• Must have experience in discharge planning/care coordination/case management

Essential Job Duties

• Conduct telephonic screenings and assessments, addressing clinical, behavioral, and socioeconomic needs of post-discharge patients.
• Identify and proactively communicate with patients with particular risk factors and diagnoses to investigate for likelihood of readmission (assess condition status, monitor for clinical deterioration, assess level of self-care and support systems) and initiate post-hospital services as needed.
• Serve as a liaison between the patient and the care team, and advocate on behalf of the patient/family/caregivers for access to services that support the patient’s preferences, quality of life, and safety and well-being.
• Reassess and respond to changes in physical, behavioral, and psychosocial circumstances, as needed.
• Collaborate and coordinate care with a multidisciplinary team in both the primary care and community setting.
• Facilitate authorization, coordination, continuity and appropriateness of care and services in the patient’s primary care setting, and connection to specialty mental health/substance use as clinically indicated by patient’s needs. Foster the connection to specialty behavioral health, while having regular and frequent touches with the patient to keep them engaged and checking on overall behavioral health stability.
• Actively engage in department and office meetings to continuously improve the Population Health/Behavioral Health services provided to high-risk, vulnerable patients.
• Compile, assess, and present findings and trends to leadership to identify areas of opportunity.