Licensed Clinical Social Worker (LCSW)

Location:

Inland Empire (San Bernardino or Riverside County)

Job Type:

Full-time, Monday-Friday Business Hours Pay:

$40.00-$58.00 per hour

Work Setting:

Hybrid. Field-Based / Community-Based with telehealth as clinically appropriate

ABOUT THE ROLE

We are seeking a Licensed Clinical Social Worker (LCSW) to provide longitudinal behavioral health and psychosocial care to an assigned panel of patients with complex behavioral, medical, and social needs. The LCSW is responsible for assessing patient needs, developing and advancing individualized care plans, providing appropriate clinical interventions, coordinating behavioral health and community services, identifying and responding to patient risk, and collaborating with an interdisciplinary care team. Patient panels may be organized around health-plan or program-defined Populations of Focus. Depending on program assignment, the LCSW may primarily serve individuals with serious mental illness (SMI), substance use disorders (SUD), co-occurring conditions, or other complex behavioral health and social needs. Clinical services may include counseling, supportive therapy, motivational interviewing, behavioral interventions, and crisis intervention. However, this role extends beyond traditional outpatient therapy and includes longitudinal care management, patient engagement, psychosocial assessment, risk assessment, care coordination, transitions of care, resource connection, and collaboration with medical and behavioral health providers. This is also a hands-on, community-based clinical role. LCSWs regularly meet patients in their homes, community settings, healthcare facilities, and other approved locations. Telehealth may be used when clinically and operationally appropriate, but regular in-person patient visits are an essential part of the position. The LCSW works closely with physicians, advanced practice providers, nurses, care managers, community health workers, behavioral health professionals, health plans, and other members of the care team to help patients achieve greater stability and improve behavioral, social, and overall health outcomes.

WHAT YOU'LL DO

Manage an assigned panel of patients and maintain appropriate ongoing engagement based on patient needs, acuity, care plans, and applicable program requirements. Conduct comprehensive behavioral health, psychosocial, functional, and social-needs assessments. Develop, implement, monitor, and update individualized behavioral health and psychosocial care plans. Serve patients within assigned health-plan or program-defined Populations of Focus, which may include individuals with serious mental illness, substance use disorders, co-occurring conditions, and significant medical or social complexity. Conduct assigned in-person visits in patient homes, community settings, healthcare facilities, and other approved locations. Provide evidence-informed clinical interventions that may include counseling, supportive therapy, motivational interviewing, behavioral activation, crisis intervention, and other clinical social work services within professional scope. Engage patients who may experience difficulty participating consistently in traditional healthcare or behavioral health settings. Assess behavioral and psychosocial risk, including suicide risk, self-harm, abuse, neglect, exploitation, domestic violence, grave disability, substance-related risk, and other significant safety concerns. Identify changes in patient condition or risk and coordinate appropriate escalation, consultation, referral, or higher levels of care. Coordinate behavioral health, medical, social, and community services necessary to advance the patient's care plan. Collaborate with physicians, advanced practice providers, psychiatric providers, nurses, care managers, community health workers, health plans, hospitals, skilled nursing facilities, and community organizations. Support continuity of care following emergency department visits, hospitalizations, skilled nursing facility stays, behavioral health crises, and other significant changes in patient status. Identify social determinants of health and psychosocial barriers that affect treatment, stability, engagement, or health outcomes and facilitate appropriate interventions, referrals, and resources. Educate patients, families, and caregivers regarding behavioral health needs, coping strategies, treatment recommendations, and available community resources. Participate in interdisciplinary case conferences, care planning, utilization discussions, and clinical case review. Complete required follow-up activities and maintain accurate, complete, and timely clinical documentation. Recognize circumstances outside professional scope, competency, or authorized responsibilities and appropriately consult, refer, or escalate.

WHO WE'RE LOOKING FOR

Required Qualifications Master's degree in Social Work from an accredited program. Current, active, and unrestricted California Licensed Clinical Social Worker (LCSW) license. Ability to provide clinical services within applicable professional scope of practice. Knowledge of behavioral health assessment, clinical social work principles, crisis intervention, and care coordination. Ability to assess behavioral and psychosocial risk and appropriately respond to or escalate clinical and safety concerns. Ability to manage an assigned patient population and prioritize needs based on patient acuity, risk, care plans, and program requirements. Strong communication skills with patients, caregivers, clinicians, health plans, and community organizations. Ability to work effectively within an interdisciplinary care model. Ability to maintain accurate, complete, and timely clinical documentation. Ability to use electronic health records, communication platforms, and other required clinical technology. Ability to regularly travel throughout the assigned service area and provide services in patient homes, community settings, healthcare facilities, and other approved service locations. Ability to reliably arrive at assigned patient and community locations as required by the position. Ability to meet applicable credentialing, screening, training, and continuing-education requirements. If driving is used to fulfill assigned travel responsibilities, ability to comply with applicable Company transportation, licensing, insurance, and safety requirements. Preferred Qualifications Experience working with medically, behaviorally, or socially complex populations. Experience in primary care, integrated behavioral health, community behavioral health, care management, or population health. Experience serving Medicare, Medi-Cal, Medicaid, dual-eligible, or other high-risk populations. Familiarity with Collaborative Care, Enhanced Care Management, Complex Care Management, or similar interdisciplinary care models. Experience conducting home- or community-based behavioral health services. Experience serving individuals with serious mental illness, substance use disorders, co-occurring disorders, or other high-acuity behavioral health needs. Experience working with patients affected by housing instability, chronic disease, frequent healthcare utilization, or other significant social or clinical complexity. Bilingual or multilingual capability based on the needs of the patient population.

WHAT DOES SUCCESS LOOK LIKE

Successful LCSWs in this role demonstrate: Effective management and engagement of an assigned patient panel. High-quality behavioral health and psychosocial assessments. Sound clinical judgment within professional scope. Appropriate identification and escalation of patient risk. Clinically appropriate interventions based on individual patient needs. Reliable completion of assigned in-person home and community visits. Consistent advancement of individualized care plans and follow-up activities. Effective coordination across behavioral health, medical, social, and community services. Strong interdisciplinary collaboration. Patient engagement and continuity of care, including with individuals who may be difficult to engage through traditional care models. Timely and accurate clinical documentation. Professional and responsive communication with patients, caregivers, health plans, providers, and members of the care team. Compliance with applicable clinical, ethical, regulatory, payer, contractual, and program requirements. Equal Employment Opportunity We are an equal opportunity employer and provides employment opportunities without unlawful discrimination, harassment, or retaliation in accordance with applicable federal, state, and local law. Qualified individuals with disabilities may request reasonable accommodation to perform the essential functions of the position. The Company will engage in the interactive process and provide reasonable accommodation as required by applicable law.

Pay:

$40.00 - $58.00 per hour Expected hours: 40.0 per week

Benefits:

401(k) Dental insurance Flexible spending account Health insurance Paid time off Professional development assistance Vision insurance

Work Location:

In person