Description

Who We Are:

Neighborhood Health Center is a non-profit organization local to Portland, OR serving underserved patients in the areas of primary care, internal medicine, dental services and more. Our patient-centered approach to care honors the unique needs and circumstances of each individual patient. NHC sees people, not problems, and recognizes that the time spent as a patient in a doctors office is only one factor in a persons overall health. Our leading edge, integrated clinical teams work in partnership with patients, their families, and the communities we serve to provide whole-person care, prevention, and ongoing support.

NHC is an Equal Opportunity Employer. We celebrate differences in the workplace and do not discriminate in employment opportunities or practices on the basis of race, color, religion, gender (sex), national origin, age, veteran status, sexual orientation, gender identity, disability, genetic information or any other characteristic protected by law.

Why work with us?

• We are a non-profit organization, passionate about providing the underserved population with medical and dental services across the greater Portland area, committed to making a difference daily.
• We offer our employees a competitive compensation and benefits package which includes 20 days of PTO (based on full time employment), 9 paid holidays, health/dental/vision insurance, quarterly wellness reimbursements, generous 401k retirement plan with employer match, employer paid disability insurance, EAP and life insurance.
• Our employees voted NHC a Top Workplace in 2020, 2021,2022, and 2023!

Job Title: Licensed Clinical Social Worker (LCSW)
Department: Behavioral Health
Reports To: Behavioral Health Manager
Work Type: On-Site (Split between Tanasbourne and Milwaukie)
Classification: Full-Time, Exempt
Language Differential: Eligible

SUMMARY

Behavioral Health Transitions of Care Case Manager will function as a core member of the Behavioral Health team, providing targeted case management to members who have recently been discharged from inpatient psychiatric hospital, emergency room or are currently in a period of transitioning to a higher needed level of care, in efforts to prevent readmission. This role will collaborate with primary care providers, health resiliency specialists, integrated CHWs for social health/basic need connection to ensure safe and adequate social needs are met during transitional period, behavioral health consultants, clinical pharmacists, and consulting psychiatrists to support continued improvement, and stabilization following discharge, or transitional periods and achieve optimal patient outcomes.

Essential Job Duties

• Conduct telephonic screenings and assessments, addressing clinical, behavioral, and socioeconomic needs of post-discharge patients.
• Identify and proactively communicate with patients with particular risk factors and diagnoses to investigate for likelihood of readmission (assess condition status, monitor for clinical deterioration, assess level of self-care and support systems) and initiate post-hospital services as needed.
• Serve as a liaison between the patient and the care team, and advocate on behalf of the patient/family/caregivers for access to services that support the patient’s preferences, quality of life, and safety and well-being.
• Reassess and respond to changes in physical, behavioral, and psychosocial circumstances, as needed.
• Collaborate and coordinate care with a multidisciplinary team in both the primary care and community setting.
• Facilitate authorization, coordination, continuity and appropriateness of care and services in the patient’s primary care setting, and connection to specialty mental health/substance use as clinically indicated by patient’s needs. Foster the connection to specialty behavioral health, while having regular and frequent touches with the patient to keep them engaged, and checking on overall behavioral health stability.
• Actively engage in department and office meetings to continuously improve the Population Health/Behavioral Health services provided to high-risk, vulnerable patients.
• Compile, assess, and present findings and trends to leadership to identify areas of opportunity.

Qualifications

QUALIFICATIONS

Education and/or Experience

• Master’s Degree in Social Work is required
• Must be a Licensed Clinical Social Worker in the state of Oregon
• A minimum of 3-5 years of relevant experience in the health care setting is preferred
• Must have experience in discharge planning/care coordination/case management

Knowledge, Skills, Abilities & Behaviors

• Must be proficient in EHR (Epic)
• Must be able to work independently exercising sound judgement, discretion, and the initiative to facilitate change
• Must have strong interpersonal skills
• Must be interested in positively impacting high-risk, vulnerable populations
• Must have excellent analytical, problem-solving abilities, interpersonal, organizational, written, and verbal skills
• Highly punctual and dependable
• High level of accuracy and attention to detail
• Ability to maintain discretion with sensitive or confidential information
• Must have excellent organizational skills
• Ability to work under direction of multiple people
• Intermediate or higher proficiency of MS Office Suite (Outlook, Word, Excel, and PowerPoint) and Adobe Acrobat
• Ability to effectively manage multiple tasks, sometimes with conflicting deadlines
• Ability to work independently and within a team setting
• Familiarity with video conferencing applications and software
• Excellent grammar, spelling, and proofreading skills
• Excellent written and verbal communication skills
• Ability to work flexible hours occasionally as needed

WORKING CONDITIONS

• Regularly sit while working on the computer; use hands and fingers to handle, control or feel objects tools or controls; repeat the same movements when entering data; ability to differentiate between colors, shades, and brightness; read from a computer screen for extended periods of time.
• Frequently stand and walk around the office to gather supplies, required to do filing, use office equipment, or collaborate with employees.
• Occasionally stand, stoop and lift or move objects, equipment and supplies weighing approximately 20-25 pounds up to 40-50 pounds.
• The noise level in the work environment is usually moderate.

Neighborhood Health Center Employment Offers are contingent on successful completion of reference checks, background checks, drug screening for illegal substances, Tuberculosis, and any position specific credentialing or licensure requirements.