Description

POSITION SUMMARY

The LCSW/LPC works in collaboration with physicians, behavioral health clinicians and other staff at The Wright Center for Community Health to address barriers to medical and behavioral health care. The LCSW/LPC addresses complex social needs of the underserved, uninsured, or underinsured community members. This role serves in an expanded clinical role to collaborate with community members, primary care providers, behavioral health providers, dental providers, community agencies, insurance companies, and other health and community-related entities to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. The LCSW/LPC expertise is sought to assess, develop, and implement member care plans as it relates to addressing the social determinants of health and optimizing the members’ physical and psychosocial health status. This is to ensure the member of the program has the resources necessary to achieve their highest level of functioning. This position works specifically with the Ryan White Program clients and others associated with the program.

Requirements

ESSENTIAL JOB DUTIES AND FUNCTIONS

While living and demonstrating our Core Values, the LCSW/LPC will:

• Works with program leadership in the design, implementation, and evaluation of the program’s objectives to the underserved, uninsured, underinsured, and newly insured populationsAssist with developing coordinated care plans for members with complex medical/social/behavioral health needs. Fosters a collaborative team approach by working with the member, family, primary care provider, behavioral health clinician, community agencies, and other members of the treatment team to ensure coordination of services
• Assist to identify outreach, wellness and education planning needs of the community member and communicate findings to the treatment team
• Coordinate referrals between and among physical, behavioral and dental health providers and other community resources to improve overall community member outcomes. Ensures appropriate clinical management information is shared with peers, providers and outside agencies in a timely fashion while securing system privacy standards
• Maintain required documentation for all program related activities. Collect data and utilize data to adjust the care plan when indicated
• Act as a patient advocate in order to coordinate required services or to resolve emergency problems in crisis situations. Provides individual and/or family education/counseling to assist in establishing members' overall wellbeing
• Utilize evidenced based counseling techniques such as motivational interviewing and solution focused skills with focus on conflict resolution, assertiveness, problem solving, and decision making to assist member with effectively negotiating the healthcare continuum
• Document patient encounters and contacts made on behalf of patients in EMR; maintains comprehensive electronic patient files, which include patient notes, release of information, assessments and other medical documents acquired on behalf of the patient
• Educate patients on the proper use of the emergency department and provide information for alternatives. Coaches patients in effective management of their chronic health conditions and self- care. Assists patients in understanding care plans and instructions. Motivates patients/patients to be active and engaged participants in their health and overall wellbeing. 
• Continuously expand knowledge and understanding of community resources and services.
• Facilitate communication and coordinate services between providers and the patients/patients. Coordinates and monitors services, including comprehensive tracking of patients' compliance in relation to care plan objectives
• Provide patient support groups to patients within the RW/ID clinic
• Work collaboratively and effectively within a team. Establishes positive, supportive relationships with participants and provides feedback to other members of the team. Builds and maintains positive working relationships with the patients, providers, care managers, medical residents, and office staff. Work to reduce cultural and socio-economic barriers between patients and institutions
• Attend weekly huddles and morning/afternoon mini huddles when possible
• Other duties as assigned

REQUIRED QUALIFICATIONS:

• Master’s degree in social work, counseling, psychology or related field is required
• Must possess Pennsylvania LPC or LCSW license
• Pennsylvania Social Work licensure required
• Must possess valid PA driver’s license
• Current BLS Certification
• Both adult and pediatric specific experience preferred but not required 
• Knowledge of the basic concepts and principles of managed care required
• Knowledge of Ryan White regulations and an understanding of the patient population required
• Knowledge of community resources required
• General computer knowledge and capability to use computers required
• Demonstrates the ability to interact in an effective manner with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse opinions, values and cultural ideas
• Demonstrates ability to work autonomously and be directly accountable for practice
• Demonstrates ability to influence and negotiate individual and group decision-making
• Demonstrate the ability to function effectively in a fluid, dynamic, and rapidly changing environment
• Demonstrate leadership qualities including time management skills, verbal and written communication skills, listening skills, problem solving/decision-making skills, work delegation and work organization
• Demonstrates ability to be self-directed, flexible, and committed to the team vision
• Demonstrates teamwork, initiative and willingness to learn, accepts and respects diversity without judgment, and demonstrates strong customer service values