The Sr. Clinical Social Worker is the primary interface for patients to access services such as peer/family counseling and support, screening, assessment, brief treatment, consultative services, education and engagement, linkages, outreach and advocacy. The Sr. Clinical Social Worker is responsible for the delivery of patient centered mental health, substance abuse, and health behavior care to assigned JHM patients through multidisciplinary primary care teams. Additionally, this position will work with MESH and MDPCP physicians, mid-levels, primary care providers, or inpatient medical teams to promote qualitative and efficient use of health care services through changing the patient’s behavior and modifying the care delivery system.
Specific Duties & Responsibilities:
In partnership with other care team members, constructs global care plan with initial POC goal setting framework (patient and treatment team program goals).
Re-evaluates plan of care with patient and other MESH/MDPCP treatment providers on quarterly basis.
Establishes initial and on-going therapeutic relationship with MESH/MDPCP patients.
Responds to all requests for new patient evaluations in a timely manner
Evaluates all new patients using established clinical evaluations developed.
Communicates results of assessment to staff involved in patients’ care.
Participates in development of an initial plan of care to address prioritized needs of patient.
Provides ongoing services as prescribed on plan of care.
Based on HBS clinical assessment, makes referrals for additional services (like PRP, IOP, rehabilitation programs, etc.) as needed.
Provides mental health, substance abuse, and health behavior services using established best practices treatment interventions.
Actively participate in multi-disciplinary rounds and care team meetings to develop tools to integrate BH interventions with team.
Coordinates care with other team members including serving as a liaison to other mental health support as necessary.
Provides outreach to patients if he/she disengages from treatment.
Establishing baseline of self-efficacy and existing social support structures and develop as needed.
Engages with community resources to ensure patient is receiving necessary services.
Screen for trauma and provide crisis intervention and trauma-informed care as needed.
Maintain network of and assists patients in securing community resources.
Performs other clinical duties as assigned.
Completes initial evaluations using established procedures according to Health Behavioral Specialist policy timelines.
Completes plan of care using established procedures according to Health Behavioral Specialist policy time lines.
Delivers ongoing care as defined in the plan of care using established procedures according to Health Behavioral Specialist policy time lines.
Writes progress notes according to established procedures according to Health Behavioral Specialist policy time lines.
Updates plan of care using established procedures according to Health Behavioral Specialist policy time lines.
Submits reports, data, and statistics as required.
Assists the MESH/MDPCP teams in meeting expected performance goals.
Leverages heath indicators
Minimum Qualifications (Mandatory):
Master’s degree from a program accredited by the Council on Social Work Education or an equivalent organization approved by the Council on Social Work Education
Two years’ related experience working and delivering ongoing care to identified population in primary care or acute hospital setting.
1 year related experience in a multidisciplinary team
Trauma-informed care training
Special Knowledge, Skills, and Abilities:
Knowledge of mental illness, substance abuse, health behaviors, and community resources.
Candidate needs to be competent in multiple treatment modalities including: Motivational interviewing, Cognitive Behavioral Therapy, Behavioral activation and must have either skills or willingness to learn office based substance use disorder interventions and Health Behavior interventions.
Identifies and acts upon impending changes in member condition.
Develops, recommends and initiates corrective action through participation in team rounds and contributions to the member care plan.
High level of interpersonal skills and ability to effectively communicate with a multidisciplinary treatment staff.
Must have excellent written and verbal communication skills.
Must be self-motivated and able to work independently also must be able to work well in a team working environment.
Must be open to ongoing supervision in specific therapeutic modalities.
Must be organized and detail oriented.
Able to enter data into electronic information systems
Technical Qualifications or Specialized Certifications:
Current Social Work Licensure in State of Maryland, LCSW-C, required and must maintain license throughout duration of employment.
Valid Maryland driver’s license with less than 2 points.
Any Specific Physical Requirements for the Job:
Primary care site, hospital or community based medical environment, fast-paced requiring flexibility and adaptability.
Work is generally sedentary in nature; however, some standing, stooping, and bending are required.
Work requires concentration and constant attention to accuracy and detail for extended periods.
Work requires cross-training and coverage of colleagues across different primary care sites
Work requires daily use of a computer.
Work requires regularly handling multiple member cases involving a variety of providers, situations, deadlines and multiple priorities.
Work requires site visits (provider offices, inpatient facilities, patient homes, etc.)
Work requires attendance at company office and off-site meetings.
Classified Title: Sr. Clinical Social Worker Working Title: Sr. Clinical Social Worker Role/Level/Range: ACRP/04/MD Starting Salary Range: $52,495 to $72,210 per year Employee group: Full Time Schedule: M-F. 8:30-5:00 Exempt Status: Exempt Location: 33-MD:Johns Hopkins Bayview Department name: 10002792-SOM DOM Bay General Internal Medicine Personnel area: School of Medicine
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