Overview

• Support the mental and physical health of patients on assigned caseloads, coordinating care with medical and mental health providers.
• Screen and assess patients for common mental health and substance use disorders; facilitate engagement and follow-up.
• Educate patients about mental health and substance use disorders, and available treatment options.
• Monitor treatment response and track clinical progress through in-person or telehealth encounters.
• Support psychotropic medication adherence, side effect management, and treatment effectiveness.
• Deliver brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving, and motivational interviewing.
• Facilitate or refer patients to evidence-based psychosocial treatments and community resources.
• Participate in regular caseload consultations with psychiatric consultants and communicate treatment recommendations to providers.
• Track clinical outcomes and patient follow-up using registries, documenting encounters in the EHR or other tracking systems.
• Adjust treatment plans for patients not improving as expected, in collaboration with medical and psychiatric teams.
• Facilitate referrals to external services such as housing, employment, or specialty mental health care.

• Develop relapse prevention and self-management plans for patients nearing discharge.

• Effectively communicate and collaborate with healthcare team members to ensure safe, timely, and holistic patient care.
• Interpret and address complex patient and family needs, role modeling caring practices.
• Assess psychosocial risk factors through evaluation of prior functioning, support systems, and reactions to illness.
• Counsel patients and families on emotional, social, and financial consequences of illness/disability.
• Access and mobilize community and family resources to meet patient needs.
• Serve as a point person and liaison for cases involving abuse, neglect, guardianship, foster care, and mental health placements.
• Provide crisis intervention and de-escalation support for dangerous or potentially violent situations.
• Support patients through end-of-life care and complex guardianship or foster care cases.

• Education: Master's Degree in Social Work required.
• Licensure: Permanent LSW licensure required; LCSW preferred.
• Certifications: De-escalation certification required within 6 months of hire.
• Experience: 3-5 years preferred in mental health, child and family services, adult protective services, Veteran's Administration, or substance abuse.
• Core Skills & Knowledge:
  • Knowledge of disease impact, human behavior, and crisis intervention techniques.
  • Familiarity with legal mandates related to protective services.
  • Principles of growth and development across the lifespan.
  • Proficiency in Microsoft Excel and Word.
  • Experience working with diverse patient populations, geographically and financially.