Social Worker

Alright, let's talk about this role. It's for a Licensed Clinical Social Worker, what we call a Behavioral Health Specialist internally. This isn't your typical outpatient therapy gig; you're the anchor for our highest risk patients who are navigating hospitalizations and the complex transition back home. You'll be based in one of our centers in Cleveland, OH, working hand in hand with primary care providers to manage a specific caseload from our Behavioral Health High Priority Patient registry.

What you'll do

The core of this job is managing that BH HPP registry. You're the point person for these patients, especially those readmitted within 30 days or at serious risk for readmission. That means diving deep into the 'why' behind a hospitalization; behavioral health needs, psychosocial stressors, financial strain, family dynamics, home safety concerns, even end of life planning.

• Conduct assessments, diagnose, and develop treatment plans and interventions.
• Your day involves constant coordination: linking patients to community resources like Medicaid assistance, meal programs, medication support, or housing services.
• A big part of the work is being that bridge. You'll dialogue with our primary care doctors to educate them on behavioral health disorders and treatment options.
• You provide casework, utilization management, and discharge planning specifically to help patients function at their highest possible level after leaving the hospital.
• Ongoing phone contact and self management support for patients is standard.
• You'll maintain daily logs for reporting and attend team meetings to keep everyone in the loop.
• Documentation has to be timely, accurate, thorough, and meet specific billing guidelines. It's a crucial part of the role.

What you need to bring

We need someone who gets the unique challenges of our patient population; frail, high risk older adults. The theory is important, but applying it here is everything.

• A Bachelor's degree in Social Work is required; a Master’s Degree (MSW) is preferred.
• You must have an active LCSW license for the state you're practicing in and maintain it yearly with continuing education. Attending training seminars to keep it current is part of the job.
• At least two years of experience in social work, case management, or discharge planning is required. Another two years working in a primary care setting would be ideal.
• You need solid knowledge of counseling theories and evidence based methods for mental health and substance abuse issues in a primary care context.
• Understanding the normal sensory, cognitive, and psychosocial changes that come with aging is non negotiable.
• Skill in assessing behavioral health in older adults and providing psychosocial support to patients with cognitive impairment is key.
• You should be proficient with advance care planning/palliative care conversations and know how to intervene with challenged caregivers or family systems.
• The ability to effectively utilize community resources and provide culturally sensitive care is essential.

The practical stuff

This is a full time position. You'll adhere to strict departmental goals and quality standards. Ethical practice consistent with both our policies and professional social work standards is expected every single day. Your critical thinking skills will get a workout here; it's complex work that requires excellent interpersonal communication and sharp teamwork abilities for coordinating care between patients, families, our staff, and outside providers.

A final note

The raw posting mentioned we're different than most primary care providers. It's true. We move fast because we're growing quickly to serve more patients who really need this kind of integrated support. If you're someone who finds energy in that kind of challenge; where your clinical skills directly impact keeping people healthier at home; then I should probably see your resume.

This description lists core duties but isn't exhaustive; other tasks may be assigned.

To apply: