Clinical Social Worker - Ambulatory Care Coordination

Moab Regional Hospital • Moab, UT

1d • $35 - $43

About The Position

The Clinical Social Worker is an integral member of the Population Health and Ambulatory Care Coordination team, providing expert psychosocial support and coordination of care for patients across the outpatient continuum. This role focuses on assessing psychosocial needs, addressing barriers to care, and collaborating with multidisciplinary partners, including Nursing, Case Management, Behavioral Health, and providers—throughout the organization. The Clinical Social Worker promotes patient well-being, continuity of care, and engagement with appropriate community-based and organizational resources, with a focus on improving patient and provider experience.

Requirements

• Master's degree in social work (MSW) from an accredited program recommended.
• Current licensure as a Licensed Clinical Social Worker (LCSW) in Utah.
• Minimum of three (3) years of social work experience in a healthcare setting, with preference for ambulatory, primary care, or population health environments.
• Demonstrated knowledge of care coordination, transitions of care, and community resource navigation.
• Strong interpersonal, communication, and advocacy skills with the ability to work collaboratively across departments and disciplines.
• Familiarity with EHR systems and data-driven case management models.
• Dedication to patient-centered, culturally competent care and organizational collaboration.

Responsibilities

• Conduct comprehensive psychosocial assessments for patients to identify emotional, social, financial, and environmental barriers impacting health outcomes.
• Develop and implement individualized care plans to address identified needs, promoting access to medical, behavioral, and community support services.
• Collaborate closely with Case Management, Nursing, and provider teams to coordinate care transitions and ensure continuity across inpatient, outpatient, and community settings.
• Assist patients and families in understanding treatment plans, available health services, and eligibility for benefits, including Medicare, Medicaid, and community-based programs.
• Provide short-term counseling, crisis intervention, and supportive therapy within the scope of practice to promote coping and adherence to care.
• Coordinate referrals to behavioral health specialists, community agencies, and social service organizations to address complex psychosocial needs.
• Participate in multidisciplinary team meetings to review care plans, identify high-risk patients, and support population health initiatives.
• Document all interventions and communications accurately within the electronic health record (EHR), maintaining compliance with regulatory and organizational standards.
• Contribute to performance improvement efforts and assist in developing workflows that enhance access, quality, and patient experience in the ambulatory environment.

Benefits

• Medical Insurance
• Mental health coverage for entire family
• Retirement 403b
• Paid time off
• Collaborative and supportive workplace
• Professional growth opportunities including continuing education, trainings, and more!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level