Licensed Clinical Social Worker

Position Overview:

Eleanor Slater Hospital is seeking a dedicated Clinical Social Worker to support a complex inpatient population, including individuals with Severe and Persistent Mental Illness (SPMI), Intellectual and Developmental Disabilities (IDD), Substance Use Disorders (SUD), and co-occurring psychiatric, cognitive, or medical conditions.

This role focuses on comprehensive assessment, clinical casework, and the development of individualized discharge plans that safely transition patients to the least restrictive and most clinically appropriate community settings. Successful candidates will demonstrate strong clinical, organizational, and collaborative abilities within a multidisciplinary environment.

Key Responsibilities:

Assessment & Reassessment:

• Conduct comprehensive psychosocial assessments upon admission.
• Develop initial discharge goals and complete ongoing reassessments throughout hospitalization.
•  Identify patient strengths, risks, barriers, and functional needs to guide treatment planning.
• Identify barriers to placement and collaborate with the treatment team to create goals and strategies to reduce or eliminate those barriers.

Discharge Planning:

• Develop, coordinate, and continuously re-evaluate individualized discharge plans.
• Facilitate placement in appropriate levels of care (e.g., nursing homes, group homes, shared living, assisted living, transitional housing, IOP, SUD programs, LTSS waivers).
• Coordinate referral submissions, service applications, placement visits, and patient transition activities.
• Provide ongoing updates and ensure compliance with the Utilization Review process and payer/regulatory requirements.

Supportive Counseling & Casework:

• Provide supportive counseling to assist patients and families with coping and adjustment.
• Engage families, guardians, and natural supports (with patient consent) to enhance treatment and discharge outcomes.
• Educate patients and families on rights, resources, and expectations related to treatment and community services.

Financial Coordination:

• Assist patients with applications for Medicaid, SSI, disability benefits, Medicare and other entitlements.
• Coordinate with state benefit and financial agencies to resolve patient eligibility needs.

Multidisciplinary Collaboration:

• Participate in treatment team meetings to develop clinically appropriate goals and interventions.
• Educate team members on community resources, program eligibility, and placement barriers.
• Maintain ongoing communication to support patient-centered care planning.

Legal Coordination:

• Coordinate with state and hospital legal departments regarding forensic, guardianship, and court-mandated cases.
• Maintain necessary legal documentation and assist with compliance requirements.

Patient Advocacy & Support:

• Advocate for patient rights, needs, and preferences.
• Assist patients with personal necessities, personal needs funds, and mail management.
• Support patients in essential off-campus outings such as funerals, family visits, and residential pre-placement visits.

Documentation & Compliance:

• Complete assessments, case notes, discharge plans, and required submissions accurately and in accordance with policies.
• Maintain compliance with accrediting bodies, audits, service standards, and professional ethics.
• Ensure all Utilization Review documentation reflects discharge planning efforts and progress.

Required Knowledge, Skills & Abilities:

• Advanced knowledge of psychiatric disorders, IDD, SUD, and co-occurring conditions.
• Strong clinical assessment, crisis intervention, and discharge planning skills.
• Familiarity with behavioral health systems, LTSS, housing options, and community resources.
• Effective communication, teamwork, and interpersonal skills.
• Ability to manage complex caseloads and competing priorities.
• Knowledge of guardianship law, forensic processes, and mandated treatment standards.

Minimum Qualifications:

• Master’s degree in Social Work (MSW) or Counseling (MS).
• Current LICSW or LMHC or eligibility for equivalent state licensure.
• Experience working with SPMI, IDD, SUD, or high-acuity behavioral health populations preferred.

Work Environment:

This role requires regular collaboration in an interdisciplinary healthcare setting, high-acuity clinical decision-making, and management of sensitive patient information. Interactions with hospital administrative units, community providers, and legal agencies are frequent.

• Candidate must have a Master's Degree and licensure in Social Work or other related field including Licensed Mental Health Counselor.