Licensed Clinical Social Worker (LCSW)

MFM Health • Danvers, MA

21d • $80,000 - $92,000

About The Position

MFM Health is seeking a compassionate, proactive, and resourceful Social Worker to join our integrated Primary Care team. In this role, you will work collaboratively with our Nurse Care Manager and medical providers to support high-risk patients by addressing social determinants of health, facilitating care coordination, and enhancing patient outcomes through resource navigation and outreach. What We Offer: Enhanced Benefits Package: Enjoy a comprehensive benefits package that includes discretionary paid time off to ensure a healthy work-life balance and a 401(k) plan with employer match. Professional Growth Environment: At MFM Health, we are committed to your professional development. We offer continuous opportunities for learning and career advancement in a supportive and collaborative environment. Key Responsibilities: Assess and address social determinants of health impacting patients’ well-being, such as housing instability, food insecurity, transportation, financial stress, and access to care. Connect patients and families with appropriate community resources including public assistance programs, support groups, housing services, and behavioral health services. Conduct post-discharge outreach to patients recently released from hospital or inpatient care to ensure continuity of care and successful transitions. Provide emotional and practical support to patients and families facing significant life changes, including chronic illness, disability, aging, or caregiver burden. Support resource navigation by helping patients understand and access complex systems including insurance, public programs, and social services. Assist with care coordination by collaborating with the Nurse Care Manager and providers to ensure timely implementation of specialty referrals and follow-up care. Bridge the gap between medical and social care, ensuring that care plans are responsive to both clinical needs and social realities. Maintain accurate documentation in the electronic health record (EHR) and participate in team-based care meetings. Qualifications: Master’s Degree in Social Work (MSW) from an accredited institution; LCSW or equivalent state licensure preferred. Minimum of 2 years of experience in a healthcare, primary care, or community-based setting. Strong understanding of social determinants of health and experience with vulnerable or high-risk populations. Knowledge of local community resources and social service agencies. Excellent communication, organizational, and interpersonal skills. Ability to work both independently and collaboratively in a fast-paced, team-based environment. Proficiency with electronic health records and case management tools. Preferred Experience: Experience working in a primary care or interdisciplinary care team setting. Familiarity with motivational interviewing or trauma-informed care approaches. Familiarity with community resources, elder services, and housing assistance.

Requirements

• Master’s Degree in Social Work (MSW) from an accredited institution; LCSW or equivalent state licensure preferred.
• Minimum of 2 years of experience in a healthcare, primary care, or community-based setting.
• Strong understanding of social determinants of health and experience with vulnerable or high-risk populations.
• Knowledge of local community resources and social service agencies.
• Excellent communication, organizational, and interpersonal skills.
• Ability to work both independently and collaboratively in a fast-paced, team-based environment.
• Proficiency with electronic health records and case management tools.

Nice To Haves

• Experience working in a primary care or interdisciplinary care team setting.
• Familiarity with motivational interviewing or trauma-informed care approaches.
• Familiarity with community resources, elder services, and housing assistance.

Responsibilities

• Assess and address social determinants of health impacting patients’ well-being, such as housing instability, food insecurity, transportation, financial stress, and access to care.
• Connect patients and families with appropriate community resources including public assistance programs, support groups, housing services, and behavioral health services.
• Conduct post-discharge outreach to patients recently released from hospital or inpatient care to ensure continuity of care and successful transitions.
• Provide emotional and practical support to patients and families facing significant life changes, including chronic illness, disability, aging, or caregiver burden.
• Support resource navigation by helping patients understand and access complex systems including insurance, public programs, and social services.
• Assist with care coordination by collaborating with the Nurse Care Manager and providers to ensure timely implementation of specialty referrals and follow-up care.
• Bridge the gap between medical and social care, ensuring that care plans are responsive to both clinical needs and social realities.
• Maintain accurate documentation in the electronic health record (EHR) and participate in team-based care meetings.

Benefits

• discretionary paid time off
• 401(k) plan with employer match
• continuous opportunities for learning and career advancement in a supportive and collaborative environment
• excellent benefits
• top-notch training
• vibrant work environment

What This Job Offers

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