LCSW Care Coordinator

LCSW Care Coordinator
Location: Granville Primary Care, Oxford NC

About Granville Health System:

For over a century, Granville Health System has been at the forefront of quality healthcare. To cater to the evolving needs of its community, Granville Health System has extended its services throughout Granville County, ensuring convenient medical care access for its residents. The Granville Health System main campus can be found at 1010 College Street, Oxford, North Carolina. For more details, visit GHS online at

About Oxford, NC

Oxford, NC is a charming and welcoming community that offers a perfect blend of small-town charm and modern convenience, making it an ideal place to live and work. Located just about 30 miles north of Durham and 40 miles from Raleigh. The region enjoys a mild, four-season climate with warm summers, crisp autumns, blooming springs, and gentle winters-perfect for enjoying the area's outdoor activities year-round. With a thriving local economy, excellent healthcare facilities, and a strong sense of community, its historic downtown, scenic parks, and proximity to the Research Triangle ensure a balanced lifestyle with both professional and personal fulfillment.

Position Overview:

LCSW Care Coordinator is an integral member of the Granville Health System Primary Care team and serves as a core participant in the Collaborative Care Model (CoCM). Working closely with Primary Care Providers, psychiatric consultants, and other healthcare team members, the BHCM provides care coordination, behavioral health assessment, brief therapeutic interventions, patient engagement, and ongoing monitoring for patients experiencing behavioral health conditions.

The LCSW Care Coordinator supports a population-based approach to behavioral healthcare, utilizing evidence-based screening tools, patient registries, and measurement-based care to improve patient outcomes. The position promotes integrated care delivery by helping patients access behavioral health services within the primary care setting while collaborating with psychiatric specialists and community resources as needed.

Position Highlights:

• Retirement Benefits: NC Local Government Pension Plan (5-year vesting period)
• Loan Forgiveness: Eligible employer for Public Service Loan Forgiveness (PSLF)
• Comprehensive Benefits: Medical, dental, vision, life insurance, and various supplemental benefits available

Key Responsibilities

Clinical Assessment and Intervention
• Conduct comprehensive behavioral health assessments utilizing evidence-based screening tools, including PHQ-9, GAD-7, AUDIT-C, C-SSRS, and other validated instruments.
• Administer and interpret evidence-based behavioral health screening and outcome measurement tools.
• Deliver brief evidence-based interventions including behavioral activation, motivational interviewing, problem-solving therapy, supportive counseling, and psychoeducation.
• Conduct suicide risk assessments and develop safety plans when indicated.
• Utilize measurement-based care principles to monitor symptom improvement and treatment effectiveness.

Care Management and Population Health
• Maintain an active caseload of patients enrolled in the Collaborative Care Program.
• Utilize a patient registry to monitor clinical outcomes, treatment adherence, and follow-up needs.
• Screen for and assess social determinants of health (SDOH).
• Connect patients with transportation, housing, food assistance, financial assistance, and other community resources.
• Collaborate with community agencies and healthcare partners to reduce barriers to care.
• Document SDOH needs, referrals, and outcomes.

Collaborative Care Coordination
• Serve as the primary liaison between patients, Primary Care Providers, psychiatric consultants, and community behavioral health resources.
• Prepare patient case presentations for psychiatric case review meetings.
• Collaborate with psychiatric consultants and providers to implement treatment recommendations.
• Support integration of behavioral health services within Primary Care workflows.

Documentation, Compliance, and Billing
• Document all patient encounters accurately and timely within the electronic medical record.
• Track Collaborative Care Model activities and time requirements to support CMS billing requirements.
• Ensure compliance with CMS CoCM requirements, HIPAA regulations, Joint Commission standards, and organizational policies.

Quality Improvement and Program Development
• Participate in development and refinement of the Collaborative Care Program.
• Monitor program metrics, patient outcomes, enrollment, and satisfaction.
• Support provider and staff education regarding integrated behavioral health services.

Qualifications
• Active, unrestricted North Carolina license as an LCSW, LCMHC, or LMFT.
• Master's degree in Social Work, Counseling, Marriage and Family Therapy, or related behavioral health field.
• Minimum of two (2) years of clinical experience in behavioral health.
• Experience working with adult patients in outpatient, primary care, integrated care, or community behavioral health settings.
• Experience utilizing measurement-based care tools, including PHQ-9 and GAD-7.
• Knowledge of evidence-based behavioral health interventions.
• Strong interpersonal, communication, and care coordination skills.
• Proficiency with electronic health records and clinical documentation.

Preferred
• Experience working within the Collaborative Care Model (CoCM).
• Familiarity with CMS billing requirements for CPT codes 99492, 99493, and 99494.
• Experience working with psychiatric consultation models, including NC STEPS or similar integrated care programs.
• Experience utilizing patient registries and measurement-based care approaches.
• Experience addressing social determinants of health and coordinating community resource referrals.
• Experience working with rural and underserved patient populations.
• Telehealth experience.

Critical Competencies
• Demonstrated knowledge and application of the DSM-5 for diagnostic assessment and treatment planning.
• Proficiency in conducting Comprehensive Clinical Assessments (CCAs) and behavioral health evaluations.
• Working knowledge of North Carolina Medicaid behavioral health regulations.
• Expertise in developing and implementing person-centered treatment plans that align with patient goals and clinical needs.
• Ability to provide services using evidence-based treatment modalities appropriate to patient diagnosis and level of care.
• Skilled in crisis assessment and intervention, including de-escalation techniques and emergency response planning.
• Competency in conducting suicide and homicide risk assessments, safety planning, and appropriate documentation.
• Ability to select and apply a variety of therapeutic approaches and treatment models based on patient presentation, diagnosis, and clinical needs.
• Experience facilitating individual, family, and group therapy services, including psychoeducational groups.
• Ability to effectively manage and maintain a productive caseload while meeting organizational productivity and documentation standards.
• Knowledge of population health principles and strategies to improve behavioral health outcomes across diverse patient populations.
Professional & Interpersonal Competencies
• Commitment to delivering patient-centered, compassionate, and recovery-oriented care.
• Strong care coordination and resource navigation skills, including collaboration with medical providers, community agencies, and support services.
• Demonstrated ability to work effectively within a multidisciplinary team environment.
• Excellent critical thinking, clinical judgment, and problem-solving skills in complex patient situations.
• Strong understanding and application of cultural humility, cultural competence, and trauma-informed care principles.
• Ability to establish and maintain therapeutic relationships with patients from diverse backgrounds.
• Effective verbal and written communication skills, including timely and accurate clinical documentation.
• Strong organizational, time management, and prioritization skills with the ability to manage competing demands.
• Ability to adapt to changing healthcare environments, workflows, and regulatory requirements.
• Commitment to continuous quality improvement, professional development, and evidence-based practice advancement.
Additional Behavioral Health Competencies
• Demonstrates cultural awareness and sensitivity when providing behavioral health services.
• Maintains professional boundaries and adheres to ethical standards of practice.
• Supports patient engagement, activation, and self-management through education and motivational techniques.
• Ability to identify social determinants of health and incorporate them into treatment planning and care coordination.

Apply Today:
If you're a dedicated professional looking for a position with a focus on work-life balance and the opportunity to make a difference, we encourage you to apply for this position with Granville Health System.