License Clinical Social Worker

HarmonyCares Clinical Social WorkerHarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. HarmonyCares operates home-based primary care practices in 14 states. HarmonyCares employs more than 200+ primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model. Our mission is to bring personalized, quality-based healthcare to the home of patients who have difficulty accessing care. Our values include caring with legacy, going the extra mile, and empowering and supporting each other.ResponsibilitiesThe Clinical Social Worker is an integral member of the care team and contributes to the care coordination for patients with multiple social stressors and/or behavioral health concerns. The Clinical Social Worker utilizes screening criteria for the coordination of quality health care services, reduction of service fragmentation, enhancement of quality of life, and the appropriate use of healthcare and community resources.Essential Duties and ResponsibilitiesManage a caseload of high-risk socially complex patientsConduct face to face and telephonic psychosocial assessments with the patient and/or the caregiverInvestigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needsProvide short-term counseling services as neededCoordinate services to ensure the patient/family understands a treatment planWork as part of a collaborative care team to achieve optimal quality and patient experience outcomes, including being an active member in High-Risk HuddlesProvide outreach to community-based services to support the patient's ability to age at homeDevelop and implement shared goals of care with the patient and familyWork with community-based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independenceIn this role you may work with:ProvidersSupport staffCare TeamPatientsPatient FamiliesCaregiversFacilities3rd party entitiesExternal ProvidersCommunity ResourcesQualificationsRequired Knowledge, Skills and ExperienceMaster's degree in social workMust be licensed as an LCSW or LISW (depending upon state)Must maintain a valid driver's license and good driving recordThe ability to use sound clinical judgment and communicate clearly in both written and verbal formatsAbove average computer skillsAbility to be self-directed and able to communicate effectively with professional staff across many disciplines and programsMust have the ability to plan time effectively, balance multiple tasks, work within stringent time frames, resolve problems, identify patient service trends, determine system improvements, and implement changeAbility to share expertise with others and demonstrates an understanding of the need to foster performance improvement while achieving patient satisfaction and efficiencyPreferred Knowledge, Skills and ExperienceExperience in Care Management in community-based setting or equivalentExperience working with the chronic, complex and/or behavioral health population