Licensed Clinical Social Worker/Licensed Professional Counselor (LCSW/LPC)

About the Role

This position uses the Integrated Health Model to provide team-based care for individuals of all ages, families, and their caregivers in a whole-person oriented setting. The Licensed Clinical Social Worker (LCSW) or Licensed Professional Counselor (LPC) collaborates with physicians, behavioral health clinicians, and other care team members to address mental illness, substance use disorders, health behaviors contributing to chronic illness, life stressors, developmental risks, stress-related physical symptoms, preventative care, and patterns of health care utilization. The role focuses on addressing complex social needs of underserved, uninsured, or underinsured community members, ensuring access to quality, efficient, and cost-effective healthcare services.

The LCSW/LPC assesses, develops, and implements care plans related to social determinants of health, optimizing physical and psychosocial well-being for members aged 5-17. The role involves collaboration with community agencies, insurance companies, and healthcare providers to coordinate services and resources.

Reporting Relationships

This position reports to the Behavioral Health Manager. No positions report to this role.

Responsibilities

• Works with program leadership to design, implement, and evaluate program objectives for underserved, uninsured, underinsured, and newly insured populations.
• Assists with state-required functions for Medicaid members, including Age Out Transition Procedure and resources for members in substitute care, waiver programs, or emergency placement situations.
• Develops coordinated care plans for members with complex medical, social, and behavioral health needs.
• Fosters a collaborative team approach by working with members, families, primary care providers, behavioral health clinicians, community agencies, and other treatment team members to ensure service coordination.
• Identifies outreach, wellness, and education planning needs of community members and communicates findings to the treatment team.
• Coordinates referrals among physical, behavioral, and dental health providers and other community resources to improve member outcomes.
• Ensures timely sharing of clinical management information while maintaining system privacy standards.
• Works closely with members to apply or obtain insurance benefits and serves as a resource for the healthcare team.
• Maintains required documentation for program-related activities and uses data to adjust care plans as needed.
• Acts as a patient advocate to coordinate services or resolve emergency problems in crisis situations.
• Provides individual and family education/counseling to support members' overall well-being.
• Utilizes evidence-based counseling techniques such as motivational interviewing and solution-focused skills to assist members with conflict resolution, assertiveness, problem-solving, and decision-making.
• Documents patient encounters, contacts, and monthly reports in the EMR; maintains comprehensive electronic patient files.
• Educates patients on proper Emergency Department use and alternatives; coaches patients in managing chronic conditions and self-care.
• Assists patients in understanding care plans and motivates them to be active participants in their health.
• Expands knowledge of community resources and facilitates patient access to services such as housing, food, clothing, prenatal classes, parenting, and mental health support.
• Assists patients in utilizing community services, including scheduling appointments and completing applications for eligible programs.
• Facilitates communication and coordinates services between providers and patients; monitors compliance with care plan objectives.
• Works collaboratively within a team, establishing positive relationships with participants and providing feedback to team members.
• Builds and maintains positive working relationships with patients, providers, care managers, medical residents, and office staff.
• Works to reduce cultural and socio-economic barriers between patients and institutions.
• Attends weekly huddles and morning/afternoon mini-huddles.
• Practices 40 hours of patient care per week.
• Performs other duties as assigned.

Requirements

• Master’s degree in social work, counseling, psychology, or a related field is required.
• Pennsylvania LPC or LCSW license required; Pennsylvania Social Work licensure also required.
• Valid PA driver’s license.
• Current BLS Certification.
• Both adult and pediatric-specific experience required.
• Knowledge of managed care concepts and principles.
• Knowledge of community resources.
• General computer proficiency.
• Ability to interact effectively with practitioners, interdisciplinary healthcare teams, community agencies, patients, and families with diverse opinions, values, and cultural ideas.
• Ability to work autonomously and be directly accountable for practice.
• Ability to influence and negotiate individual and group decision-making.
• Ability to function effectively in a fluid, dynamic, and rapidly changing environment.
• Leadership qualities, including time management, verbal and written communication, listening, problem-solving, decision-making, work delegation, and organization.
• Self-directed, flexible, and committed to the team vision.
• Demonstrates teamwork, initiative, willingness to learn, acceptance of diversity, and strong customer service values.

Skills

• Buy-in and experience working in the EOS® model (strongly preferred).
• Mission-oriented with professional representation of the organization.
• Proficiency in evidence-based counseling techniques (e.g., motivational interviewing, solution-focused skills).
• Strong advocacy, coordination, and collaboration skills.
• Ability to assess, develop, and implement care plans addressing social determinants of health.
• Experience in data collection and utilization for care plan adjustments.