Licensed Social Worker

COPE Health Solutions•Los Angeles, CA

6d•Hybrid

About The Position

The Licensed Social Worker works within the interdisciplinary care team for the Care at Home Solutions program. This independently licensed clinician partners with the Medical Director, Advanced Practice Provider, Registered Nurse, Pharmacist, Community Health Worker, and Care Navigators to address behavioral health needs, improve psychosocial well-being, and support patients in achieving their health goals. The role includes comprehensive behavioral health assessment, evidence-based counseling and brief interventions, individualized care planning, crisis intervention when appropriate, and connecting patients with community behavioral health and social support resources. The position is hybrid with an LA office location, travel of up to 50%, and a standard business-hours schedule with flexibility based on patient and program needs. It is full-time, exempt, pays $75,000–$96,000, reports to the Director, Care at Home Solutions, and has no direct reports. Care at Home Solutions is a community-based, physician-led care model serving people with multiple chronic conditions and elevated healthcare utilization. Its multidisciplinary team connects with patients in their homes and other care settings to provide clinical assessment, care management, navigation, and support for health-related social needs. The program coordinates with primary care providers, specialists, health plans, and community partners to support continuity of care and reduce avoidable emergency department visits and hospitalizations.

Requirements

Valid and current California licensure or registration as an Associate Clinical Social Worker (ASW), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or equivalent behavioral health professional.
3–5 years of care management and/or managed care experience in acute inpatient, rehabilitation, sub-acute, skilled facility, homecare, ambulatory care management, or managed health plan settings.
Working knowledge of timely and accurate documentation of daily activities in a designated technology platform.
Ability to adapt to new technologies and software.
Knowledge of federal and state regulations for Medicare, Medicaid, and other national and state-funded programs.
Knowledge of how to access community resources.
Ability to use independent judgment and manage and convey confidential information.
Ability to analyze and solve problems by reviewing and challenging relevant details, data, and facts before making decisions.
Strong communication, listening, and interpersonal skills, including the ability to clearly communicate medical information to practitioners and/or the public.
Strong organizational, prioritization, follow-up, analytical, and time-management skills, including the ability to handle multiple priorities and deadlines.
Dependability, strong work ethic, personal integrity, proactivity, and ownership of work.
Ability to handle frequent interruptions while maintaining friendly interactions.
Ability to develop and implement approaches to improve processes, procedures, or the work environment.
Ability to review critical issues, solve problems effectively, and create action plans.

Nice To Haves

2–5 years of leadership experience in a care management/managed care setting.
Bilingual Spanish/English.
Proficiency in EMR systems, Outlook, and data entry.
Basic PC skills, including MS Word, Outlook, PowerPoint, and Excel.

Responsibilities

Assess patients to determine appropriateness for management early in their disease process and throughout the continuum of care.
Complete comprehensive assessments to identify patient risk and develop care plans, using professional expertise and judgment to evaluate the need for alternative services.
Assess members’ social determinants of health, including housing, food, transportation, and safety in the home.
Collaborate with APPs, physicians, pharmacists, nurses, registered dieticians, community resources, and other disciplines to address needs identified in assessments.
Screen members for behavioral health concerns, including depression and substance abuse, using tools such as PHQ-2 and PHQ-9, and ensure appropriate interventions.
Arrange follow-up and referrals for behavioral health needs with local providers.
Develop, facilitate, and communicate care plans in partnership with members, families or designated representatives, providers, and the multidisciplinary care team, considering care options, benefits, and community resources.
Update care plans to document progress toward established goals and self-management activities.
Coordinate referrals and authorizations relevant to patient care and well-being.
Use established systems, processes, and initiatives to engage patients in social activities that promote wellness and care at the appropriate place and time.
Support members in adopting strategies to promote physician-recommended behavior changes.
Identify and use cultural and community resources, aligning them with patients’ cultural preferences where possible.
Facilitate information flow between health representatives and the care team.
Coordinate care and communicate with multiple providers, both internal and external to the practice.
Serve as a resource for clinical and non-clinical staff, including care coordinators, community health workers, and APPs.
Attend required training and collaboration sessions, including learning sessions and practice team meetings.
Communicate openly with physicians and the Care at Home Solutions team about patient status.
Perform other job-related duties as assigned.