Clinical Social Worker

Clinical Social Worker

Position Summary

The Licensed Clinical Social Worker (LCSW) is an integral member of the interdisciplinary healthcare team, providing comprehensive psychosocial assessment, counseling, care coordination, and resource management to support older adults and other medically complex patients. Working collaboratively with the Geriatrician, Primary Care Providers, Care Coordinators, nursing staff, and community partners, the LCSW addresses psychosocial barriers to care, improves patient outcomes, and enhances quality of life through evidence-based interventions and coordinated care planning. This position will dedicate approximately 50% of time supporting the Hunterdon Center for Healthy Aging and 50% supporting Care Coordination initiatives across Hunterdon Medical Group.

Primary Position Responsibilities

1. Clinical Social Work Services Conduct comprehensive psychosocial assessments for geriatric patients and their caregivers. Evaluate social determinants of health, including housing, food insecurity, transportation, caregiver burden, financial concerns, and safety risks. Develop individualized care plans in collaboration with the Geriatrician and interdisciplinary team. Provide crisis intervention, short-term counseling, and emotional support to patients and families. Administers and documents standardized evidence-based screening tools (PHQ-9, GAD-7, Mini-Cog, MoCA, SDOH, caregiver burden, fall risk, etc.) as appropriate. Assist patients and families with advance care planning, goals-of-care discussions, and completion of advance directives. Connect patients and caregivers with appropriate community resources and supportive services. Facilitate family meetings to address care planning, disease progression, and caregiver education. Performs suicide risk assessments utilizing evidence-based screening tools and facilitates timely intervention when indicated. Collaborates with behavioral health providers regarding patients with depression, anxiety, substance use disorders, dementia-related behavioral concerns, and other psychosocial needs.

Identifies and reports suspected abuse, neglect, exploitation, or unsafe living conditions in accordance with organizational policy and state and federal regulations.

Other duties as assigned

1. Care Coordination Partner with Care Coordinators and Primary Care teams to identify high-risk patients requiring social work intervention. Assist patients transitioning between hospital, rehabilitation, skilled nursing facilities, assisted living, and home. Address psychosocial barriers that may impact treatment adherence, follow-up appointments, or chronic disease management. Collaborate with the health care team to develop comprehensive care plans for medically complex patients. Coordinate referrals to behavioral health providers, community agencies, home care, hospice, palliative care, and other support services. Advocate for patients requiring financial assistance, insurance navigation, transportation, or community resources. Maintains current knowledge of community resources, government assistance programs, payer resources, and social service agencies.

2. Interdisciplinary Collaboration Leads of facilitates interdisciplinary team meetings, case conferences, and care planning discussions for medically and psychosocially complex patients. Serve as the social work resource for physicians, advanced practice providers, nurses, and office staff. Foster collaboration between outpatient providers, hospital teams, and community agencies to ensure continuity of care. Advocates for patients and caregivers to ensure equitable access to healthcare services and community resources. Communicates effectively with providers, interdisciplinary team members, patients, families, and community partners. Provides education to patients, families, caregivers, and clinical staff regarding psychosocial issues, community resources, aging-related concerns, and behavioral health needs.

3. Quality & Population Health Support organizational initiatives focused on reducing avoidable emergency department visits and hospital readmissions. Assist with population health initiatives targeting vulnerable and high-risk patient populations. Promote healthy aging through patient education, caregiver support, and preventive resource referrals. Participate in quality improvement projects related to patient outcomes, care coordination, and social determinants of health. Demonstrates High Reliability Organization (HRO) principles by promoting a culture of safety, accountability, transparency, and continuous improvement. Identifies, reports, and escalates patient safety concerns, near misses, and process improvement opportunities.

4. Professional Responsibilities Documents assessments, interventions, care plans, referrals, patient education, and care coordination activities accurately, timely, and in accordance with organizational, regulatory, and payer requirements. Mintains complete documentation supporting medical necessity, quality reporting, and reimbursement requirements. Supports documentation requirements for care management programs including Transitional Care Management (TCM), Chronic Care Management (CCM), Principal Care Management (PCM), and Annual Wellness Visit workflows as appropriate. Maintain compliance with all regulatory, payer, and organizational documentation standards. Utilizes appropriate CPT and ICD-10 coding knowledge related to behavioral health and psychotherapy services as applicable. Maintains compliance with HIPAA, confidentiality standards, CMS Conditions of Participation, Joint Commission standards, OSHA requirements, and applicable federal and New Jersey regulations. Utilizes the electronic medical record, patient registries, population health platforms, and other technology tools to support care coordination. Maintains professional licensure and completes required organizational education and competencies. Adheres to Hunterdon Medical Group policies, procedures, and code of conduct.

Qualifications

Minimum Education:

Required:

Masters in Social Work

Preferred:

None

Minimum Years of Experience (Amount, Type and Variation):

Required:

1 year experience as LCSW

Preferred:

3–5 years ambulatory or geriatric experience

License, Registry or Certification:

Required:

Current New Jersey Licensed Clinical Social Worker (LCSW)

Preferred:

None

Knowledge, Skills and/or Abilities:

Required:

Comprehensive psychosocial assessment, geriatric behavioral health, care coordination and transitions of care, community resource management, crisis intervention, advanced care planning, knowledge of medicare medicaid, and community support services, excellent communication and interdisciplinary collaboration skills, proficiency with electronic medical records.

Preferred:

Care management experience, Behavioral health integration, Epic/NextGen experience, extensive knowledge of Medicare and community resources

Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).