Licensed Clinical Social Worker

Position purpose:

Lead the development and daily operation of an integrated behavioral health service for cardiology patients while maintaining a direct therapy caseload. Accountable for implementation, clinical workflows, staff education, reporting, and sustainable patient access; partners with practice management on budget and operations.

Direct patient care:

• Complete diagnostic interviews, psychosocial assessments, risk assessments, clinical formulations, and individualized treatment plans.
• Deliver evidence-informed individual psychotherapy for depression, anxiety, adjustment to cardiac diagnoses, post-event distress, treatment adherence and related concerns within professional scope. Provide 45- or 60-minute follow-up visits when clinically appropriate; determine frequency, duration, and discharge based on clinical need. Provide brief same-day consultations and warm handoffs from cardiologists and nurse practitioners when capacity and privacy permit.
• Monitor symptoms and outcomes using PHQ-9 and GAD-7 as appropriate; document progress, response, and revised care plans.
• Recognize suicidal ideation, severe psychiatric symptoms, or other urgent concerns; apply approved crisis and escalation protocols and arrange higher-level care when needed. Deliver respectful, culturally responsive, LGBTQ-affirming care and maintain patient privacy.

Collaborative Care (CoCM) operations:

• Explain the program, obtain and document required patient consent, and confirm eligibility with the treating practitioner and billing team.
• Maintain an accurate, secure patient registry containing treatment goals, follow-up dates, symptom scores, consultant recommendations, and status.
• Conduct scheduled phone/video/in-person outreach and track cumulative patient-specific care management time each calendar month.
• Prepare caseload reviews for the psychiatric consultant, document recommendations, and route medication suggestions to the treating prescriber; the LCSW does not independently prescribe.
• Coordinate follow-up, referrals, stepped-up treatment, and case closure with the clinical team.
• Support compliance with initiating visit, billing practitioner, time threshold, and non-duplication requirements; final coding and claim submission remain with authorized billing staff

Documentation, coordination and quality:

• Complete psychotherapy notes, diagnoses, care plans, screening results, and monthly CoCM time logs in eClinicalWorks or the approved registry.
• Communicate clinically relevant updates to cardiologists/NPs and protect separately restricted records when applicable.
• Participate in interdisciplinary huddles, consultant meetings, chart audits, and periodic quality improvement reviews.
• Maintain active licensure, professional liability coverage as assigned, required training, and applicable payer enrollment/reassignment.

Additional program leadership and implementation:

• Design and roll out screening, referral, warm-handoff, consent, registry, follow-up, crisis, and discharge workflows across the three clinics.
• Develop training materials and coach front desk, MAs, NPs, and physicians on referral criteria and operational handoffs without delegating clinical judgment to unlicensed staff. Partner with practice management to establish patient access, telehealth scheduling, dedicated room use, and site-specific staffing needs.
• Create referral-growth plans for internal cardiology referrals and appropriate community relationships; do not tie referrals to improper financial incentives.
• Coordinate psychiatric consultant meeting cadence and service expectations with leadership; contract approvals and payments remain with authorized management. Review panel capacity, no-shows, treatment response, payer denials, documentation defects, and collection trends with management monthly.
• Recommend changes to protocols, staffing, scheduling and technology; obtain management approval before financial commitments or staffing decisions.
• Provide a written 30/60/90-day implementation plan and a six-month program evaluation.

Performance scorecard (planning targets):

• 10–14 direct therapy visits/week initially, adjusted for implementation workload.
• Build toward 35 active CoCM patients, then evaluate capacity for 44–60 active patients across the practice; targets depend on referral flow and patient eligibility.
• Weekly psychiatric caseload review and timely, complete patient-specific time tracking. Target patient no-show rate below 15%, with clinic-supported reminders and access improvements.
• Monthly monitoring of PHQ-9/GAD-7 change, outreach completion, consent accuracy, patient safety and documentation quality.
• Targets are goals, not guarantees of reimbursable services; clinical appropriateness and payer rules take precedence.

Leadership deliverables:

• First 30 days: map existing workflow, finalize draft protocols and registry design, define reporting baseline.
• By 60 days: train initial-site staff, test warm handoffs and documentation, review early enrollment and access barriers.
• By 90 days: report on first-site launch, staff adoption, active panel, clinical measures, and issues requiring management decisions.
• By six months: recommend expansion sequencing and updated staffing/financial assumptions based on actual payer and referral data.

Minimum and preferred qualifications:

• Master of Social Work (MSW) from an accredited program and active, unrestricted Texas LCSW license.
• At least two years of applicable post-master’s supervised clinical experience; verify payer-specific qualifications and enrollment requirements.
• Competence in psychotherapy, suicide risk assessment, crisis response, care coordination, and clinical documentation.
• Preferred: outpatient medical or cardiology experience, CoCM/BHI experience, eClinicalWorks familiarity, bilingual English/Spanish, and telehealth proficiency.
• Must live in Houston TX

Pay: From $70,000.00 per year

Benefits:

• Flexible schedule

Work Location: Hybrid remote in Pasadena, TX 77505

Salary : $70,000