Major responsibilities:

• Conducts Comprehensive Assessments

• Facilitates medication reconciliation with pharmacist and/or primary care team

• Engages members and care givers in active care planning with a focus on, medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social care goals.

• Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up

• May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management **

• Travel throughout assigned area to engage members at their homes or other locations where the member may be located **

• Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the member’s needs and preferences.

• Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.

• In collaboration with Community Health Workers creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.

• Participates in the integrated care team meetings and rounds as required

• Maintain accurate, timely documentation in electronic systems including health center EHRs

• Provides coverage for team members who are out of office

• Demonstrate understanding and commitment of the health center mission.

• Demonstrate understanding and commitment to the established CHC Values and Standards.

• Perform other duties as assigned.

Minimum Qualifications:

• 2-3 years of Inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment and support

• Bachelor's Degree required, Master's Degree in Psychology, Social Work or related field preferred.

• Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC) preferred but not required in lieu of experience

• Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Nurses, Community Health Workers, and other health care teams

• Ability to flexibly utilize clinical expertise to solve complex problems

• Bi-lingual

• Experience working with patients with chronic and behavioral health needs

• Must be flexible and adaptable to change

• Demonstrate the ability to work independently

• Must demonstrate excellent interpersonal communication skills

• Additional qualities that would be a good fit for our team include: Enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality

• Experience using appropriate technology, such as computers, for work-based communication

• Experience and proficiency with Microsoft Office and online record keeping

• Experience working with a Medicaid population is strongly preferred

• Experience working with Federally Qualified Health Centers is strongly preferred

• A valid driver's license and provision of a working vehicle

• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations**