The Clinical Social Worker is a key member of the iCMP (Integrated Care Management Program), Accountable Care Organization (ACO) and Collaborative Care teams, providing and overseeing the provision of psychiatric, psychosocial and overall mental health services for high risk, medically complex patients.

The Clinical Social Worker is involved in assessment and triage of patients and families, to ensure provision of appropriate, timely, and effective evaluation. This initial clinical evaluation may be conducted by the social worker independently, or in collaboration with other members of the care team. The social worker collaborates with the care team and communicates relevant information.

The Clinical Social Worker may provide direct treatment/intervention to patients and families and/or may work with the treating clinicians in psychiatry, psychology, or other disciplines, within and outside of the system, helping to ensure that treatment is focused and effective.

  • Provides assessment of patients to evaluate mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse, neglect and domestic violence. Working with the care team, prepares an intervention plan and disposition.
  • Provides psychosocial assessment of families to determine:
    • family relationships/systems as they relate to care of the patient
    • identifies family decision makers and caregivers; family understanding of illness and trajectory of care
    • identifies family coping style, family resources and cultural issues
  • Employs a range of clinical interventions such as brief individual, group or family counseling. Provides caregiver/family counseling/support to promote family/caregiver cohesiveness to provide care to patient and prepare patient and families for care transitions, including end of life.
  • Advocates on behalf of patients and families to gain access to services and resources such as financial and housing. Refers patients to providers as necessary.
  • Provides brief transitional care management for patients with depression who are being discharged from an inpatient setting.
  • Provides clinical support to the behavioral health Coach (BS-level health coach on Collaborative Care team) through review of cases on a regular basis.
  • Provides support and consultation to physician practices regarding depression management.
  • Assesses when abuse is suspected and files mandated reports as indicated by guidelines.
  • Works effectively as part of the care team, communicating regularly with the care manager and other members of the care team as needed.
  • Coordinates family/team meetings as needed and when appropriate. Provides psychosocial consultation on patient care planning and patient/family management.
  • Documents timely and relevant information in patient electronic medical record and care management system and communicates this information to the care team in a timely fashion.
  • Acts as a resource to the care team and works, on a case by case basis, to coach and mentor on techniques and approaches to management of psychosocial issues in a high risk population and advocate for optimal outcomes.
  • Presents and/or discusses clinical work in formal and informal case reviews and seminars as indicated.
  • Performs other duties, as assigned.
  • Experience in field of care management, psych, substance abuse and/or community mental health services preferred.
  • Clinical experience, understanding of, and comfort working with patients of all ages who suffer complex medical and psychiatric problems; ability to work with families/caregivers of such patients, and ability to help patients and families/caregivers understand and access the resources required to support care.
  • Strong understanding of psychiatric and family system and ability to use this understanding to formulate succinct case summaries.
  • Strong clinical, consultation and care management skills especially in regards to depression management, motivational interviewing and behavioral activation.
  • Good organizational and time management skills.
  • Demonstrated ability to communicate effectively orally and in writing.
  • Strong interpersonal skills enabling effective team collaboration.
  • Demonstrated ability to be flexible and adapt to a complex, fast paced medical environment.
  • Knowledge of specific medical/psychiatric illnesses, procedures and treatments.
  • Ability to provide rapid clinical psychosocial assessments and brief, short or long term treatment/management with individuals, families, caregivers, couples and/or groups.
  • Advanced crisis intervention/treatment/management skills.
  • Demonstrated competency in age specific behaviors, cultural issues; effect of  illness, as well as family member illness, on patient.
  • Knowledge of end of life care issues.
  • Ability to work effectively as a member of a multi-disciplinary team.
  • Demonstrated ability to consult/teach.
  • Knowledge of community agencies/resources. Ability to advocate/negotiate systems for/with patients.
  • Documents in medical record according to policies and procedures.
  • Maintains confidentiality in accordance with HIPPA.


WORKING CONDITIONS: Describe the conditions in which the work is performed.

Normal office working conditions; home visits; patient visits in a community setting and in inpatient and outpatient medical and psychiatric settings.