Social Worker LCSW - Integrated Care Program, Viera, Full Time

Health First Brevard County, FL

About the Job


To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by
coordinating the psychosocial care and services for assigned/referred members in collaboration
with the member, family, physician, patient care team, and payers. The Social Work Case
Manager utilizes advanced psychosocial skills to facilitate the coordination of care through
assessment, planning, intervention, and evaluation. The Social Work Case Manager facilitates
and evaluates the effective utilization of resources, quality, and community services. The social
worker participates in quality improvement activities, serves as a professional role model,
supports and encourages staff growth and development, and supports and facilitates the
mission, goals and objectives of the department. The social worker coordinates the psychosocial
care and services for assigned patients in collaboration with the patient, family, physician, patient
care team, and payers. The social worker utilizes advanced psychosocial skills to facilitate the
coordination of care through assessment, planning, intervention and evaluation. The social
worker promotes and evaluates the effective utilization of resources using current knowledge,
awareness of community services, and serving as a role model to achieve optimal clinical and
resource outcomes. The Social Worker promotes and effectively utilizes hospital and community
resources and achieves optimal outcomes.


Quality/No Harm\:
 Assess social service referrals for appropriateness and make the necessary
recommendations for plan of care.
 Conduct, by phone or in person, comprehensive biopsychosocial assessment and
reassessments of identified members who are either high risk or in need.
 Engage in timely, member centered care planning, care plan implementation, and care
 Coordinate care to promote proper care access and care continuity, especially during
transitions of care. Care may address the individualized health, behavioral, or social
needs of the member.
 Collaborate with other members of the health care team, the member, and/or their
designated representative.
 Engage in ongoing interdisciplinary, intra-organizational, and inter-organizational
 Initiate, facilitate, and participate in care conferences and multidisciplinary rounds
 Serve as a liaison to HFHP partners, not limited to governmental agencies and community
 Provide consultation and education to the care team members of other disciplines to
promote member centric care.
 Document, in a timely manner, all case management activities in accordance with
regulatory, legislative, statutory, and organizational requirements.
 Participate in ongoing practice and program evaluation and improvement.
 Adhere to National Patient Safety Goals.
 Ensure compliance with regulatory standards at the state and federal level.
 Identifies risk management and quality issues and intervenes or refers as indicated.
 The LCSW will act as a facilitator on complex cases, which may be referred by staff in
case management or other members of the healthcare team.
 Assists with implementation of department-based performance improvement activities
resulting in improved operations and patient care outcomes.
 Assists manager with assigned audits or performance tracking needs.
 Identifies opportunities for quality improvement activities in the department.
 Will fill and take routine department assignments as needed and work with staff to fill in
when staffing needs occur. 
 The LCSW will recommend supportive and therapeutic interventions as indicated to
ensure a cost effective, safe and efficient plan of care and quality patient outcomes.
 Assess and document in case management/EMR platforms patient/family needs and
collaborates with physicians and staff to identify possible psychosocial related needs.
 Coordinates and documents complex discharge plans.
 Collaboratively determines desired discharge goals and communicates all discharge plans
and options to patient/family, physicians and staff members.
 Participates in patient care conferences/ethics consults as indicated.
 Collaborates with RN Case Manager, staff RN, ancillary staff and physicians facilitating
continuity of care for the patient, identifies "at risk" patient populations and/or strengths of
patient/family support systems on admission.
 Conducts psychosocial assessment to screen for patients/families at risk for crisis, abuse,
financial or environmental issues.
 Provides therapeutic/crisis intervention counseling with patients and families as needed.
 Provides supportive services for End of Life Issues, Terminal Care and Bereavement
issues. Coordination of adoptions with patients and families and other services as
 Provides counseling and researches placement alternatives for substance abuse, mental
health, homeless and indigent patients.
 Facilitates and participates in transfer of Baker Act and Marchman placements to mental
health facilities. Provides therapeutic interventions with patients and families as needed.
 Completes mandatory reporting processes.
 Facilitates referrals for psychosocial and therapeutic needs.
 In a crisis, where safety of the patient or others is in immediate jeopardy, the LCSW can
Baker Act a patient. 
 Bridge the gap between the clinician and the patient
 Assist in navigation of the health care system
 Build strong supportive relationship with the patient

 Communicate pertinent findings and care recommendations to appropriate team
 Participate in patient care conferences as required.
 Recommends supportive and therapeutic interventions as indicated to ensure a cost
effective, safe, and efficient plan of care and quality patient outcomes.
 Collaborate with other team members to communicate all plans of care, discuss any
barriers, and coordinate patient outcomes.

Customer Experience\:
 Reinforce and document education provided to member or representative on psychosocial
aspects of care and expected outcomes
 Provide and document education to members of the team regarding appropriate services
and referrals available for the situation at hand.
 Maintain and improve clinical skills related to therapeutic methods, developmental
theories, and disease processes.
 Participate in the education of the healthcare team members on case management and
current healthcare economic issues affecting acute care.
 Maintain current knowledge and awareness of payer/reimbursement practices and the
regulations affecting patient care.
 Initiate appropriate referrals to Ethics Committee, Risk Management, DCF, etc. as
 Participate in resolution of issues surrounding guardianship, power of attorney, etc. as
 Provides education and/or material regarding patient’s rights, informed consent, advanced
directives, etc. as appropriate.
 Drive to a member’s at home or in a facility
 Adhere to the I-CARE Values.



 Current Florida LCSW license
 Three (3) years of previous social work experience preferred.
 Case Management experience preferred
 Medical Terminology understanding
 Typing/computer skills
 Proficiency with Electronic Medical Record
 Reliable transportation and valid driver’s license
 Demonstrates ability to relate well to patients and families.
 Sound organizational skills to include time management and problem solving
 Knowledge of regulatory guidelines (state/federal)
 Highly developed communication skills, verbal and non-verbal
 Motivated to provide comprehensive complex care in an evolving environment, whilst being
flexible and innovative within this service
 Ability to work in a team and balance input from a range of sources
 Emotional intelligence and empathy
 Comfort with uncertainty and motivation to innovate