The Licensed Clinical Social Worker will function as a core member of the Behavioral Health team, providing targeted case management to members who have recently been discharged from inpatient psychiatric hospital, emergency room or are currently in a period of transitioning to a higher needed level of care, in efforts to prevent readmission. This role will collaborate with primary care providers, health resiliency specialists, integrated CHWs for social health/basic need connection to ensure safe and adequate social needs are met during transitional period, behavioral health consultants, clinical pharmacists, and consulting psychiatrists to support continued improvement, and stabilization following discharge, or transitional periods and achieve optimal patient outcomes.

Essential job duties:

• Conduct telephonic screenings and assessments, addressing clinical, behavioral, and socioeconomic needs of post-discharge patients.
• Identify and proactively communicate with patients with particular risk factors and diagnoses to investigate for likelihood of readmission (assess condition status, monitor for clinical deterioration, assess level of self-care and support systems) and initiate post-hospital services as needed.
• Serve as a liaison between the patient and the care team, and advocate on behalf of the patient/family/caregivers for access to services that support the patient’s preferences, quality of life, and safety and well-being.
• Reassess and respond to changes in physical, behavioral, and psychosocial circumstances, as needed.
• Collaborate and coordinate care with a multidisciplinary team in both the primary care and community setting.

Education and experience:

• Master’s Degree in Social Work is required
• Must be a Licensed Clinical Social Worker in the state of Oregon
• A minimum of 3-5 years of relevant experience in the health care setting is preferred
• Must have experience in discharge planning/care coordination/case management

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