30+ days ago


Cleveland, OH


Clinical Social Worker

U.S. Medical Management (USMM) is an affiliate of a leading Fortune 100 company. A national organization built on a continuum of care with premier healthcare providers, clinicians and patient focused individuals working together. Our Mission Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services Visiting Physicians Association, Pinnacle Senior Care, Grace Hospice, Comfort Hospice, Home DME & our In Home Health Assessments (IHA).

Our Values of Integrity, Respect, Teamwork & Excellence are leading us to a better tomorrow for patient care. Our Purposes Centered on We are Unified in our Work through our Continuum of Services We can Find Comfort that We are Making a Difference for our Patients & We make a Broader Positive Impact on Society , allows USMM to be poised for a phenomenal future.

We are seeking candidates who desire the experience of delivering quality & compassionate healthcare within proven care models with patients at the forefront of everything we do.


Benefits We Have to Offer: 

  • Health, Dental, Vision, Disability & Life Insurance
  • 401K Retirement Plan
  • Paid Holidays
  • PTO 
  • Flexible Spending Account
  • Tuition Reimbursement

Position Description

The Clinical Social Worker works collaboratively with the Care Team to provide care management services based on comprehensive assessments addressing an individual s ability to maintain independence  in the home, chronic care management, end of life decisions, cognitive/functional status, frequency acute care utilization, and a patient/caregiver support system.  

Contributes to the care coordination for individuals with multiple social stressors and/or behavioral health concerns by utilizing screening criteria developed for the overall purpose of coordination of quality health care services, reduction of service fragmentation, enhancement of quality of life, and the appropriate use of health care and community resources.


Essential Duties and Responsibilities

  • Manages a caseload of high risk socially complex patients by:
    • Conducting face to face and telephonic psychosocial assessment with the patient and/or the caregiver
    • Investigating psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needs.
    • Coordinating services to ensure the patient/family understands a treatment plan
    • Providing outreach to community based services to support the patient s ability to age at home
    • Developing and implementing shared goals of care with the patient and family
  • Provides feedback to the home based primary care physician (HBPCP) to ensure he/she is aware of any early patient changes
  • Counsels and provides crisis intervention for patients, including assessment and treatment of emotional and behavioral problems 
  • Counsels patients on how to manage ongoing health conditions and provides therapy to help patients make positive behavior changes
  • Performs comprehensive assessment for mental health, substance abuse, co-occurring disorders, domestic violence and medical needs. Conducts follow-up as appropriate based on results of evaluation
  • Assesses the needs and develop appropriate response plans for patients by interviewing patient, families, and caregivers
  • Provides emotional support, mental health evaluations, therapy and case management services to patients experiencing psychological, emotional, medical, social and/or familial challenges.
  • Counsels patients to gain access to various resources and assist patients to confront issues that are negatively affecting their way of living such as poverty, abuse, mental health and addiction.
  • Performs short term counseling and crisis intervention as necessary
  • Participates in Multidisciplinary Care Planning Rounds
  • Conducts additional psychosocial assessments as patient needs change
  • Works with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independence
  • Other duties/projects as assigned
  • Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes


REQUIRED Knowledge, Skills and Experience

  • Master s Degree in Social Work
  • Current unrestricted Social Work License or Limited License with preceptor or must be a licensed and boarded CSW or become licensed and boarded within 1-year
  • Must maintain a valid driver s license and good driving record
  • 3 years of experience in Care Management in community based setting or equivalent
  • The ability to use sound clinical judgment and communicate clearly in both written and verbal formats
  • Above average computer skills
  • Ability to be self-directed and able to communicate effectively with professional staff across many disciplines and programs
  • Must have the ability to plan time effectively, balance multiple tasks, work within stringent time frames, resolve problems, identify patient service trends, determine system improvements, and implement change
  • Ability to share expertise with others and demonstrates an understanding of the need to foster performance improvement while achieving patient satisfaction and efficiency
  • Experience with the homebound population, managed care, ACO, medical home or integrated case management environment is preferred


Preferred Knowledge, Skills and Experience

  • Experience working with the chronic, complex and/or behavioral health population