Licensed Social Worker

TEEMA; San Jose (CA); On-site; USD 75,000 - 105,000; Full time

Job summary

TEEMA is seeking a dedicated Social Worker to deliver psychosocial assessments, care coordination, counseling, and referrals under supervision. This role emphasizes compassionate, patient-centered support and collaboration with families and care teams to improve independence and quality of life.

The ideal candidate holds an MSW, has experience with frail or elderly populations, and is comfortable with documentation, EHR systems, and team-based care. On-site work with potential community visits.

Qualifications

• MSW from an accredited institution required.
• Bachelor’s in Social Work may be considered with relevant experience and language proficiency.
• Minimum of one (1) year of experience working with frail or elderly populations.

Responsibilities

• Provide psychosocial assessments and develop individualized care plans.
• Collaborate with caregivers and support systems to deliver coordinated care.
• Offer individual counseling and facilitate family conferences and caregiver groups.
• Identify psychosocial risks and advocate for necessary referrals and services.
• Coordinate discharge planning and community resources.

Skills

Interpersonal skills

Collaboration

Communication

Documentation

Microsoft Office

Bilingual ability

Clinical care coordination

Education

Master of Social Work (MSW)

Bachelor’s degree in Social Work (BSW)

Tools

EHR systems

Electronic documentation systems

Job description

The Social Worker provides compassionate and comprehensive case management services to patients, empowering them and their families to maintain independence and enhance quality of life. Working under the supervision of the Regional Social Work Manager, with guidance from the Center Director and support from the Social Work Lead, this role is an essential part of the team. The Social Worker delivers psychosocial assessments, care coordination, counseling, and referrals to community resources—ensuring patients receive the individualized support they need to thrive.

This is an excellent opportunity for a motivated, empathetic, and organized professional who values teamwork, meaningful connections, and making a direct impact on people’s lives.

Duties and Responsibilities

Clinical Practice & Case Management

• Exercise independent judgment to provide case management services for a panel of patients.
• Conduct comprehensive initial and routine psychosocial assessments to develop, implement, and update individualized care plans.
• Collaborate with caregivers and support systems to establish and deliver coordinated care plans.
• Identify psychosocial risks, challenges, and service needs; advocate, refer, coordinate, and follow up on patient support in a timely manner.
• Provide individual counseling to patients as needed.
• Facilitate family conferences and patient/caregiver support groups.
• Engage with the community to identify and access services that support patient well‑being.
• Conduct discharge planning and coordination when a patient transitions out of the program.
• Participate in special events such as caregiver workshops and educational sessions.
• May review and verify assessments completed by other social work staff.
• Serve as a primary liaison between patients, caregivers, the team, and community partners.
• Collaborate with external agencies such as healthcare plans, community‑based organizations, and care facilities.
• Adhere to ethical and legal standards of social work practice.
• Comply with all organizational policies and procedures, including safety and confidentiality regulations.
• Complete all documentation promptly and accurately.
• Actively participate in team meetings, advocate for patient and caregiver needs, and contribute to collaborative care planning.
• Support continuous improvement efforts to enhance service quality and operational efficiency.
• Deliver 5-star service guided by compassion, respect, and professionalism.
• Perform other related duties as assigned.

Required Qualifications

• Master’s degree in Social Work (MSW) from an accredited institution required.
• Bachelor’s degree in Social Work may be considered with relevant experience and language proficiency.
• Minimum of one (1) year of experience working with frail or elderly populations.

Licenses and Certifications

• Valid Social Worker license in the state of California (MSW – Medical Social Worker).

Knowledge, Skills, and Abilities

• Experience and ability to work effectively with diverse populations.
• Skilled in collaborative teamwork and interdisciplinary care coordination.
• Strong interpersonal skills with the ability to build trust and rapport with patients, caregivers, and colleagues.
• Highly organized with the ability to prioritize, manage multiple tasks, and follow up thoroughly.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office and comfortable using electronic documentation systems.
• Bilingual ability may be required for specific assignments.
• Strong foundation in clinical practices and case management principles.

Desired Qualifications

• One (1) year or more of post-MSW experience.
• Prior experience in case management or healthcare settings.
• Familiarity with electronic health record (EHR) systems.

Location and Work Type

Work Type:

On-site, with responsibilities that may include visits to patient homes, community settings, and care facilities.