Licensed Clinical Social Worker

Definition:

As a core member of the interdisciplinary care team, the Licensed Clinical Social Worker (LCSW)

serves as the primary lead for psychosocial assessment, caregiver engagement, and non-clinical

risk mitigation for patients enrolled in ACO REACH, GUIDE, and other value-based care models.

The LCSW provides longitudinal support to patients and caregivers by identifying social risk

factors, supporting caregiver stability, coordinating community-based resources, and partnering

with clinical team members to reduce avoidable utilization and improve quality of life.

responsibilities:

• Conduct comprehensive psychosocial assessments for ACO REACH and GUIDE patients,

focusing on social determinants of health, behavioral health needs, caregiver support,

and gaps in care.

• Conduct ongoing reassessments as patient condition, caregiver capacity, and disease

progression evolve, including identification of safety risks, caregiver strain, and

psychosocial factors that may increase utilization or compromise care in the home.

• Develop patient-centered care plans in collaboration with the clinical team (NPs, PCPs,

Care Coordinators) to support risk reduction, chronic disease management, and quality

metric improvement.

• Ensure care plans are actionable, updated longitudinally, and aligned with patient goals,

caregiver capacity, and available community resources.

• Participate in interdisciplinary team meetings to discuss patient status, symptom burden,

social needs, and next steps in care.

• Perform proactive outreach to high-risk patients identified through population health

tools.

• Engage caregivers proactively as part of outreach activities, particularly for patients at

risk of functional decline, behavioral escalation, or avoidable emergency department

utilization.

• Support patients, families, and caregivers by providing education to improve patient

engagement and functional outcomes.

• Provide longitudinal caregiver education, coaching, and emotional support, including

anticipatory guidance regarding disease progression, strategies for managing behavioral

symptoms, stress and burnout mitigation, and decision support related to care

transitions.

• Provide supportive counseling addressing anticipatory grief, coping with serious illness,

stress, caregiver burden, and adjustment to progressive diseases.

• Coordinate referrals to community resources including housing, transportation, food

assistance, utilities, mental health services, and caregiver programs.

• Act as a central navigator across medical providers, community-based organization, and

long-term services and supports, including respite care, adult day programs, in-home

support services, and financial or legal assistance.

• Coordinate resources related to hospice transition, in-home support services, respite

programs, community mental health, caregiver support, and financial assistance.

• Facilitate goals of care conversations and advance care planning (POLST, healthcare

proxy).• Support ongoing goals-of-care discussions in collaboration with clinical team members,

recognizing that patient preferences and caregiver readiness may change over time.

• Document psychosocial findings, care plans, interventions, and patient outcomes in

accordance with palliative care standards.

• Document caregiver interactions, assessments, interventions, and care coordination

activities in a manner that supports quality reporting, utilization management, and

compliance with CMS program requirements for GUIDE and other value-based care

models.

• Contribute to program outcomes including caregiver stability, reduced avoidable

utilization, timely care transitions, and sustained patient engagement. Participate in

quality improvement initiatives and workflow refinement related to value-based care

performance.

• The Social Worker reports directly to the Director of Nursing of Intrinsia Health.

Required Qualifications / Skills:

1. 2. 3. Master’s degree in social work (MSW)

Licensed Clinical Social Worker (LCSW) or equivalent state licensure

Experience working with Medicare-aged patients, including individuals with serious

illness and cognitive impairment such as dementia.

4. 6. Ability to work independently and as part of a multidisciplinary team

5. Strong ethical standards

Excellent communication and interpersonal skills

Preferred Qualifications / Skills:

1. 2. Palliative Care, Home Health, or Hospice experience

Experience working in value-based programs (e.g., PACE, Medicare Advantage, ACOs,

CMS demonstration models, all-inclusive insurance programs)

3. Experience delivering billable services and documenting services in support of quality

measurement and/or utilization management.

Salary : $47 - $50