Licensed Clinical Social Worker

Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as long delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

Why Is This Role Critical?

The primary role of the Social Worker is to assess the psychosocial needs of patients and provide focused care delivery to address issues that impede their ability to adhere to their care plan.  The SW is an active member of the Interdisciplinary Care Team (IDT).  

KEY RESPONSIBILITIES 

• Assess patients’ psychosocial concerns and the impact on their current medical status
• Develop collaborative care plan goals with the patient, IDT members, Care Team Pod, and their family/ caregiver
• Assess and document current advance care directive status and ongoing efforts to reconcile patient/caregiver misaligned goals with current clinical status
• Connect patient and/or their family/caregiver to appropriate community resources and supports
• Collaborate on and support plan of care as determined by the physician and Care Team Pod
• Perform initial assessment and periodic re-evaluation of the patient and adjustments in the patient’s treatment plan 
• Provide treatment to patients per protocols, policies, and clinical practice guidelines
• Facilitate transitions of care for assigned patients per Upward Health policy; coordinate care across the continuum of care
• Identify innovative actions to meet the needs of the patient from both the health care and psychosocial /socioeconomic dimensions of care as well as taking action for provision of services to meet those needs
• Make care recommendations of the multidisciplinary care team, the patient, family and caregiver
• Initiate and maintain ongoing communications with clinicians involved in member care, especially the PCP and Psychiatrist
• Provide short-term, risk-focused care management
• Utilize motivational interviewing and other psychotherapeutic techniques to elicit behavior change
• Promote patient self-management strategies
• Enhance and support connectivity between patients and members of the interdisciplinary team
• Navigate community resources and develops partnerships to improve access to care and ease of systems navigation.
• Identify and report any quality of care issues or concerns
• Ensure strict compliance with federal and state regulations and company policies, procedures and processes 
• Attend departmental meetings
• Complete other duties as assigned

KNOWLEDGE, SKILLS & ABILITIES

• Interpersonal savvy, demonstrated by the ability to interact with and empower patients 
• Entrepreneurial and operational mindset to create, execute, and measure outcomes for ongoing performance improvement 
• Demonstrated skill in motivational interviewing technique
• The can-do attitude required for a role at a start-up company
• Ability to go deep in the community with knowledge of local and state resources to support patients needs
• Excellent written, computer, and oral communication skills – will proactively and thoroughly communicate with other members of the team 

 
MINIMUM QUALIFICATIONS

• Three (3) years of social work experience (internship not included), with 2 years of social work experience in a healthcare setting (physician’s office, PCMH, hospital, clinic, home care or nursing home setting)
• Working knowledge of Medicaid and Medicare, and managed care organizations
• Excellent communication skills and knowledge of accessing community resources
• Master’s Degree (MSW) in Social Work OR Master's Degree in Psychology or related discipline 
• Possession of a valid state driver’s license and access to an automobile
• Meet all state certification and licensing requirements

 PREFERRED QUALIFICATIONS

• Experience in delivering home care or field case management is preferred

Upward Health is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.  This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. 

All roles at Upward Health are considered Hybrid.  There is always an expectation depending on the role for travel into our corporate office, the markets we serve and/or into the communities where our amazing patients are.   Our recruiting team would be happy to discuss this further with you during your screening.  

**We require all our employees to be vaccinated, and be able to show proof upon hire**