Clinical Social Worker

This program is dedicated to preventing unnecessary emergency department (ED) visits and hospitalizations by delivering proactive, patient-centered care that improves health outcomes, reduces healthcare costs, and supports patients in achieving their personal health goals.

The Social Worker brings expertise in behavioral health, crisis intervention, social determinants of health (SDOH), and patient advocacy within an interdisciplinary care team.

Primary Responsibilities

• Conducts comprehensive behavioral health assessments using validated tools such as PHQ-9, GAD-7, CAGE, and ACEs to identify mental health concerns, and develops behavioral health care plans integrated with medical and social interventions.
• Provides brief, evidence-based therapeutic interventions, including Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT)-informed techniques, and Solution-Focused Therapy; offers psychoeducation on stress management, coping strategies, and behavioral activation.
• Provides substance use disorder support and harm reduction, including comprehensive SDOH assessments and interventions; conducts screenings to identify social barriers impacting health, including housing instability, food insecurity, transportation issues, and financial stressors.
• Works to reduce unnecessary behavioral health emergency department visits and behavioral health hospital admissions by identifying high-risk patients using real-time ED visit alerts, hospital discharge data, and predictive analytics to provide early intervention.
• Focuses on crisis prevention and de-escalation by providing early intervention for patients with escalating behavioral health or social crises, ensuring appropriate community-based support is in place, offering same-day or next-day behavioral health support for patients experiencing acute distress, and working with community behavioral health agencies and law enforcement alternatives to divert patients from unnecessary ED use.
• Collaborates with primary care providers (PCPs), behavioral health specialists, urgent care clinics, and community mental health programs to ensure patients access lower-acuity care settings instead of the ED; works with pharmacists to resolve medication-related ED visits.
• Provides post-hospitalization support by conducting post-discharge outreach within 24–48 hours to assess social, behavioral, and logistical barriers to recovery, identify patients at high risk for readmission, and ensure they have intensive post-hospital support.
• Works with each member of the care team to serve as the behavioral health and SDOH expert, ensuring medical, behavioral, and social care are seamlessly integrated.
• Provides patient education on substance use disorder and mental health concerns and assists clinical teams in evaluating a patient’s need for behavioral health services.
• Able and willing to travel and meet with patients at practice locations, hospitals, emergency departments, and patient homes within a defined region of care; this is a hybrid role requiring travel and onsite work at least four days a week.
• Other duties as assigned.