Job Details
We are seeking a qualified, empathetic, relationship-driven Licensed Clinical Social Worker to be a part of our start up company and help shape and deliver clinical care services for residents in Senior Living Communities (SLCs) in collaboration with community Primary Care Providers (PCPs). This Lead role is critical as first on the ground with facilities, PCPs, and residents. You will establish positive, professional collaborative relationships with SLCs and PCPs in program/ service development, resident care coordination and provide direct clinical care to residents. While this role is majority patient facing, this Lead role will also provide direct feedback and review of internal company start up care materials and workflow.
You will assist older adults with challenges related to mental health, aging, and support seniors in managing health care, planning for long-term care, and maintaining a good quality of life. Your direct-patient care role will be providing brief clinical interviews, solution-focused interventions, care coordination and engagement, and community resource navigator. You will work under program criteria and guidelines in order to deliver high quality evidence based integrative behavioral health services. This includes reviewing patients' charts and intake information, conducting initial visits with residents in SLC, creating care goals, and following up care plan interventions, including care coordination in collaboration with their PCP. The majority of this care will be provided in person directly with the residents in the SLCs. You will also build community resources for residents in order to help provide coordinated care.
What You Will Do:
- Manage a panel of patients in Senior Living Communities (SLCs) with mild to moderate behavioral health conditions in close collaboration with the primary care provider
- Create and maintain positive, professional relationships with SLC clinical and operational staff and PCPs
- Review and provide program workflow and development feedback as StealthCo evolves both in clinical ops and technology
- Provide brief interventions using evidence based techniques such as behavioral health activation, problem-solving treatment, motivational interviewing, goal setting, and other treatments appropriate for residents in SLCs
- In person and Virtually (sync & async) monitor patient on a regular basis in regards to psychosocial needs, education, and compliance with treatment plan
- Communicates with PCPs and SLCs to report patient progress, needs, concerns, and potential and actual problems to optimize, reinforce and support care plans
- Develops and maintains through knowledge of referral and community resources throughout the service area
- Chronic Care Management (CCM) and Collaborative Care Model (CoCM) and other care service program coordination
- Provide social work services including, short term counseling, community resource planning, and crisis intervention
- Document patient progress and treatment recommendations so they can be easily shared with PCPs, SLCs, other care coordination staff and outside treating providers
- Participate in ongoing care collaboration, through team-based case conferences, maintain a patient registry, electronic communication channels, and with provider partners
- Additional responsibilities as needed
What you will need:
- A Master degree in social work, nursing, or other applicable behavioral health disciplines from an accredited college or university is required
- Licensed Certified Social Worker within the state of Florida
- 3+ years of outpatient healthcare work experience
- Competency with brief, structured intervention techniques (e.g. Motivational Interviewing, Behavioral Activation, Problem Solving Treatment)
- Competency in screening skills, assessments and foundational knowledge for common mental health disorders
- Proficient in Microsoft Word, Google Suite (calendar, docs, sheets, slides, etc.)
Preferred Education & Experience
- Geriatric population experience
- Spanish verbal & written proficiency
- Additional state licenses (PA, MI, CT) and/or willingness to obtain additional licenses as needed with business growth
- Mental Health/ Behavioral Health Startup
Location
- This is a hybrid role based in Brevard County FL (Titusville/ Melbourne)
- You will work on the ground performing care services to residents in local SLCs
- Your home will be your office when not in SLCs - ensuring you have HIPAA compliant space