Complex Care Coordinator (LSW)

PHMC is proud to be a leader in public health. PHMC requires that all employees are fully vaccinated with the Covid-19 vaccine before the first day of employment.

Mission Statement :

Our Mission is to be the premier regional provider of integrated, community-based healthcare by combining evidence-based clinical practices, outstanding patient service, innovative care partnerships, and team-driven excellence, within a healthy fiscal environment.

Licensed Social Worker (LSW) sought to work as a part of an interdisciplinary complex care management team. The LSW will report to the RN Complex Care Manager and will be an integral part of the Specialized Health Services interdisciplinary team across the PHMC nurse-managed Health Network sites. The LSW will work at these health centers and in the community with diverse and underserved patient populations The LSW will provide community-based clinical social work, case management and outreach services to help coordinate care and improve patient health outcomes. This position provides clinical hours towards the LCSW. The LSW will receive clinical supervision from an LCSW from within the Health Network as well as training and support the Health Network social services team.

Responsibilities :

• Provide multidisciplinary assessments by evaluating all relevant information to determine needs and barriers in health care, social supports, and access to behavioral health services
• Actively participate as a member of the interdisciplinary health care team (IDT) by providing input and developing creative strategies to address health, behavioral health, and psychosocial issues
• Collaborate with medical and auxiliary providers in developing health care plans and goal based on identified needs
• Provide outreach and engage with clients by eliminating social, cultural, linguistic, and educational barriers to promote and encourage self-care
• Facilitate communication and positive relationship building between clients and medical providers
• Ensure that clients obtain timely and coordinated access to appropriate health and social services by promoting and modeling advocacy skills

Individual counseling including : Functional and strength-based assessment and diagnosis

Psychoeducation for patients and their support systems

Medication adherence counseling and disease self management counseling

Motivational Interviewing to develop behavioral strategies aimed at symptom reduction

Brief problem solving cognitive intervention aimed at modifying negative thinking and promoting self efficacy

Substance use / abuse evaluation, identification of maladaptive coping strategies, and development of harm reduction strategies

Skills :

Experience :

Education Requirement :

Physical Demands :

Work Environment :

Salary :

Commensurate with education and experience

PHMC is an Equal Opportunity and E-Verify Employer.