Licensed Clinical Social Worker - Community

Licensed Clinical Social Worker for Integrated Community Care

Come launch the next step in your career where America launched its Space Program. Brevard Health Alliance, Brevard County's only Federally Qualified Health Center, is currently recruiting for a Licensed Clinical Social Worker for Integrated Community Care to join us in the heart of Brevard County's Space Coast. Since 2005 our focus has been on putting the "community" in Community Health while delivering healthcare to more than 60,000 unique patients annually.

Brevard Health Alliance offers competitive salaries, a comprehensive hiring package that includes Medical, Dental, Vision, Short and Long-term Disability Coverage and a 401K with company match, a generous personal leave program, a National Health Service Corps (NHSC) Approved Site for Loan Repayment and Qualified Employer for Public Service Loan Forgiveness, tuition assistance for continuing education, professional development, and the opportunity for upward mobility.

We are expanding, we are growing. If you would like the genuine opportunity to make a profound difference in the delivery of primary care and community health, we invite your interest and application after reviewing the specifics and requirements for the Licensed Clinical Social Worker for Integrated Community Care listed below.

Position Summary

Provide in-home psychosocial assessment, counseling, care coordination and caregiver support for complex, homebound patients. Work collaboratively with a multidisciplinary team (physicians, nurses, resource specialists, case managers, and community agencies) to implement and monitor individualized psychosocial treatment plans that support medical goals, safety, behavioral health and patient/caregiver wellbeing. Provide telehealth services as appropriate with patients and/or their caregivers.

General Education Requirements

A Master's Degree in social work from a Council on Social Work Education (CSWE) accredited school of Social Work. See Florida Statute Chapter 456: Health Professions and Occupations.

Additional Qualifications

• Current LCSW license in the state of Florida.
• Minimum 2 years clinical experience providing home-based, geriatric, hospice/palliative, or medically complex patient services preferred.
• Proficient in Electronic Medical Records (EMR)
• Proficient in the operations of Federally Qualified Health Centers (FQHC)
• Demonstrated experience working with multidisciplinary teams and family/caregiver systems.
• Strong assessment, crisis intervention, problem-solving, and care coordination skills.
• Valid driver's license, reliable transportation, and ability to travel to patient homes.
• Automated office and PC experience required
• Current Basic Life Support (BLS)/CPR certification from the American Heart Association or the American Red Cross

Primary Accountabilities

• Conduct comprehensive psychosocial assessments in the home to identify behavioral health needs, social determinants of health, safety risks, caregiver strain, and service gaps.
• Develop, implement, and monitor individualized psychosocial care plans aligned with the medical plan of care; adjust plans in collaboration with the multidisciplinary team.
• Provide brief individual, couples, and/or family psychotherapy, crisis intervention, care coordination, and caregiver support in the patient's home.
• Serve as primary psychosocial liaison between the patient/caregiver and the multidisciplinary team; communicate assessment findings, progress, and concerns to clinical leads, providers, and resource specialists.
• Support caregivers with education, skill-building, referrals to respite and support groups, and strategies to reduce burnout and improve patient functioning.
• Assist Resource Specialists and case managers with complex referrals, triage, and transitions of care (hospital to home, home to hospice, etc.).
• Provide community outreach and representative liaison services as needed to connect patients with home-based supports and programs.
• Deliver in-service training and case consultation to staff and caregivers on psychosocial needs, safety planning, dementia/behavioral strategies, and community resources.
• Maintain accurate, timely documentation in the medical record and comply with confidentiality, regulatory and organizational policies.
• Participate in interdisciplinary team meetings, quality improvement initiatives, and performance metric reviews to support organizational goals (productivity, quality, patient satisfaction, retention).
• Resolve patient and caregiver concerns at the lowest appropriate level; escalate issues when necessary.
• Perform other related duties as assigned
• Takes ownership and represents Brevard Health Alliance's mission and organizational goals established by the executive committee. These include, but are not limited to: Productivity, Quality, Patient Satisfaction, and Employee Retention. It is the duty of each BHA employee to incorporate these goals into all daily work routines, and strive to achieve and surpass all goals by working as a team. The mission and goals of BHA will be incorporated into each associate's Key Performance Indicators and will be evaluated on a monthly and quarterly basis.