Licensed Clinical Social Worker - Transitions of Care (LCSW)

Central Health; Austin (TX); On-site; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a skilled Clinical Social Worker to enhance care transitions for patients with complex needs. This role involves delivering trauma-informed assessments, counseling, and case management to support individuals as they move from acute care settings to their homes or rehabilitation centers. The ideal candidate will possess a Master's Degree in Social Work and an LCSW license, bringing a compassionate approach to care that respects patient autonomy and dignity. Join a dynamic team dedicated to improving patient outcomes and ensuring a seamless continuum of care in a supportive environment.

Qualifications

• Master's Degree in Social Work required with 2 years of post-graduate experience.
• LCSW license in Texas is mandatory upon hire.

Responsibilities

• Provide trauma-informed care coordination for patients transitioning from hospitals.
• Conduct biopsychosocial assessments and develop comprehensive treatment plans.
• Advocate for patients' needs and facilitate care coordination with community partners.

Skills

Trauma-informed care

Biopsychosocial assessments

Crisis intervention

Patient advocacy

Mental health counseling

Psychoeducation

Education

Master's Degree in Social Work

Tools

DSM-V

Health literacy resources

Job description

Overview

Central Health is looking for a skilled Clinical Social Worker (LCSW-TOC) to join the Transition of Care (TOC) program to provide comprehensive coordination and continuity of care support to individuals with complex acute or chronic conditions as they transition from hospitals to rehabilitation centers, their homes, or other care settings. In collaboration with patients, their identified support persons, providers, and staff across all disciplines, the LCSW-TOC is responsible for providing strengths-based biopsychosocial-spiritual assessments and the delivery of brief trauma-informed counseling, holistic case management, psychoeducation, and other relevant services to support successful care transition with the goal of reducing hospital readmission and increasing permanency in the community. Depending on the needs of individuals served, program offerings may be provided within the field and/or in a virtual capacity. The LCSW-TOC shall demonstrate a trauma-informed approach to care that is compassionate and sensitive to client needs while respecting one's rights to self-determination and dignity.

Responsibilities

Essential Functions

1. Work to support safe and seamless continuity of care through the delivery of trauma-informed care coordination services as patients transition through the acute care to community setting.
2. Complete ongoing assessment of the multi-dimensional and holistic biopsychosocial-spiritual needs, strengths, and goals including the impact of social determinants of health on transitions of care planning for patients.
3. Provide diagnostic impression of mental health and/or substance use disorders utilizing the DSM-V and deliver effective evidence-informed and emerging best practice clinical treatments.
4. Identify and evaluate patient-centered evidence-informed clinical interventions offered as part of a comprehensive treatment plan developed in partnership with the patient and interdisciplinary TOC team.
5. Actively foster a safe, supportive, and healing environment for all patients and their identified support systems.
6. Provide trauma-informed and culturally affirming brief counseling for individuals to support and enhance a patient’s overall well-being.
7. Advocate with internal and external stakeholders for continued focus on the choices, values, and preferences of the patient.
8. Facilitate the coordination of care between the TOC team and external community partners, including resolving potential barriers to transition of care plan achievement and support the patient's overall treatment experience.
9. Provide strengths-based psychoeducation in areas including but not limited to health literacy, harm reduction strategies, and medication management to support patient understanding and well-being.
10. Respond to mental health and substance use related crises through the provision of trauma-informed crisis intervention, de-escalation, risk assessment, and other evidence-informed interventions to patients.
11. Support the TOC program's continuous quality improvement and utilization management initiatives and activities to ensure high-quality standards of patient care.
12. Attend and participate in scheduled staff meetings, supervision sessions, trainings, and other relevant meetings necessary for the clinical, administrative, and operational functions of the TOC program.
13. Complete all direct and indirect patient care documentation in accordance with professional standards, program procedures, and relevant local, state, and federal regulations.
14. Maintain knowledge of community resources and other benefits necessary to refer clients for services and to advocate for client needs, priorities, and goals.
15. Foster a collaborative and professional environment within the organization and with external community partners.
16. Attend relevant professional development training to ensure the delivery of best clinical practices and maintain all licensure and/or certification requirements.
17. Perform other duties as assigned.

Qualifications

Master's Degree in Social Work from an accredited institution - Required

2 years post-graduate experience in care coordination with complex patient populations and/or therapeutic counseling - Required

Required upon hire:

• LCSW- License Clinical Social Worker (Texas)
• Heartsaver First Aid CPR AED obtained through the American Heart Association or American Red Cross