Central Health is looking for a skilled Clinical Social Worker (LCSW-TOC) to join the Transition of Care (TOC) program to provide comprehensive coordination and continuity of care support to individuals with complex acute or chronic conditions as they transition from hospitals to rehabilitation centers, their homes or other care settings. In collaboration with patients, their identified support persons, providers and staff across all disciplines, the LCSW-TOC is responsible for providing strengths-based biopsychosocial-spiritual assessments and the delivery of brief trauma-informed counseling, holistic case management, psychoeducation, and other relevant services to support successful care transition with the goal of reducing hospital readmission and increasing permanency in the community. Depending on the needs of individuals served, program offerings may be provided within the field and/or in a virtual capacity. The LCSW-TOC shall demonstrate a trauma-informed approach to care that is compassionate and sensitive to client needs while respecting one's rights to selfdetermination and dignity.

Essential Functions
Work to support safe and seamless continuity of care through the delivery of trauma-informed care coordination services as patients transition through the acute care to community setting.
Complete ongoing assessment of the multi-dimensional and holistic biopsychosocial-spiritual needs, strengths, and goals including the impact of social determinants of health on transitions of care planning for patients.
Provide diagnostic impression of mental health and/or substance use disorders utilizing the DSM-V and deliver effective evidence-informed and emerging best practice clinical treatments.
Identify and evaluate patient-centered evidence-informed clinical interventions offered as part of a comprehensive treatment plan developed in partnership with the patient and interdisciplinary TOC team.
Actively foster a safe, supportive and healing environment for all patients and their identified support systems.
Provide trauma-informed and culturally affirming brief counseling for individuals to support and enhance a patients overall wellbeing.
Advocate with internal and external stakeholders for continued focus on the choices, values and preferences of the patient.
Facilitate the coordination of care between the TOC team and external community partners, including resolving potential barriers to transition of care plan achievement and support the patient's overall treatment experience.
Provide strengths-based psychoeducation in areas including but not limited to health literacy, harm reduction strategies, and medication management to support patient understanding and well-being.
Respond to mental health and substance use related crises through the provision of trauma-informed crisis
intervention, de-escalation, risk assessment, and other evidence-informed interventions to patients.
Support the TOC programs continuous quality improvement and utilization management initiatives and activities to ensure high-quality standards of patient care.
Attend and participate in scheduled staff meetings, supervision sessions, trainings, and other relevant meetings necessary for the clinical, administrative and operational functions of the TOC program.
Complete all direct and indirect patient care documentation in accordance with professional standards, program procedures and relevant local, state and federal regulations.
Maintain knowledge of community resources and other benefits necessary to refer clients for services and to advocate for client needs, priorities and goals.
Foster a collaborative and professional environment within the organization and with external community partners.
Attend relevant professional development training to ensure the delivery of best clinical practices and maintain all licensure and/or certification requirements.
Perform other duties as assigned.

Master's Degree in Social Work from an accredited institution - Required
2 years post-graduate experience in care coordination with complex patient populations and/or therapeutic counseling - Required

Required upon hire:

LCSW- License Clinical Social Worker (Texas)
Heartsaver First Aid CPR AED obtained through the American Heart Association or American Red Cross