Job Description

Company Overview:

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs – everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals – because we know that health requires care for the whole person. It’s no wonder 98% of patients report being fully satisfied with Upward Health!

Job Title & Role Description:

The  Licensed Clinical Social Worker (LCSW)  at Upward Health plays a crucial role in assessing and addressing the psychosocial needs of patients. As a member of the interdisciplinary care team (IDT), the LCSW collaborates with team members to develop comprehensive care plans that address both the medical and emotional well-being of patients. This position involves applying behavioral intervention techniques such as Motivational Interviewing, trauma-informed care, and person-first thinking. The LCSW also works to connect patients and their families to community resources, facilitates transitions of care, provides short-term, risk-focused care management, and intervenes during crises when necessary. This role ensures that patients receive comprehensive care while promoting patient self-management and autonomy.

Skills Required:

• Licensed Clinical Social Worker (LCSW) with all state certification and licensing requirements met.
• Minimum of three (3) years of social work experience, with at least two (2) years in a healthcare setting (e.g., physician's office, PCMH, hospital, clinic, home care, or nursing home).
• Knowledge of Medicaid and Medicare, as well as managed care organizations.
• Strong communication skills, both oral and written, with the ability to collaborate effectively with multidisciplinary teams.
• Experience in home care or field case management is preferred.
• Working knowledge of local and state resources to support patient needs.
• Ability to assess and address Social Determinants of Health (SDOH).
• Ability to manage patient crises and provide focused care interventions.
• Valid state driver’s license and access to an automobile.
• Bilingual in English and Spanish is preferred.

Key Behaviors:

Collaboration: 

• Works closely with interdisciplinary team members to integrate behavioral health considerations into patient care.

Empathy: 

• Demonstrates understanding and compassion when interacting with patients and their families, fostering positive therapeutic relationships.

Accountability: 

• Takes ownership of care delivery, ensuring adherence to clinical guidelines and policies.

Adaptability: 

• Adjusts approaches to care as needed, responding to the dynamic healthcare needs of patients.

Initiative: 

• Identifies innovative solutions to patient needs across both healthcare and psychosocial dimensions.

Leadership: 

• Guides the care team in applying best practices in behavioral health interventions and ensuring effective care coordination.

Competencies:

Clinical Expertise: 

• Proficient in behavioral health intervention techniques, including Motivational Interviewing, trauma-based care, and other person-centered approaches.

Community Engagement: 

• Strong ability to navigate and connect patients with local community resources and services.

Communication: 

• Excellent verbal and written communication skills, with the ability to clearly communicate complex health and social information to patients and team members.

Crisis Intervention: 

• Demonstrates the ability to intervene in patient crises, offering immediate and appropriate solutions.

Patient-Centered Care: 

• Promotes self-management and patient autonomy while ensuring that care plans align with patient values and goals.

Documentation: 

• Maintains accurate and timely patient records, adhering to all regulatory and company standards.

Problem-Solving: 

• Effectively identifies and addresses barriers to care, proactively finding solutions to improve patient outcomes.

Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.

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