Clinical Social Worker - Ambulatory Care Coordination

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Clinical Social Worker - Ambulatory Care Coordination

Quick overview

The Clinical Social Worker provides expert psychosocial support and care coordination for outpatients by conducting comprehensive assessments to identify barriers impacting health outcomes. Responsibilities include developing individualized care plans, collaborating with multidisciplinary teams, and connecting patients with necessary medical, behavioral, and community resources.

Requirements summary

Candidates must possess a Master's degree in social work (MSW) from an accredited program and hold current licensure as a Licensed Clinical Social Worker (LCSW) in Utah. A minimum of three years of social work experience in a healthcare setting, preferably ambulatory or population health, is required, along with strong skills in care coordination and resource navigation.

postgraduate degreeCase ManagementAdvocacyCare PlanningCounselingCrisis InterventionCare CoordinationPopulation HealthPatient EngagementInterdisciplinary CollaborationBehavioral HealthPsychosocial AssessmentsPerformance ImprovementCulturally Competent CareEHR DocumentationSocial WorkCommunity Resource Navigation

Job description

Clinical Social Worker – Ambulatory Care Coordination Location

Moab
Regional
Hospital
Department:
Care
Coordination
Reports To:
Director of
Case
Management
Starting pay range: $34.50 to $43.00/hour, DOE.

Position Summary

The Clinical Social Worker is an integral member of the Population Health and Ambulatory Care Coordination team, providing expert psychosocial support and coordination of care for patients across the outpatient continuum. This role focuses on assessing psychosocial needs, addressing barriers to care, and collaborating with multidisciplinary partners, including Nursing, Case Management, Behavioral Health, and providers—throughout the organization. The Clinical Social Worker promotes patient well-being, continuity of care, and engagement with appropriate community-based and organizational resources, with a focus on improving patient and provider experience. Primary Responsibilities
Conduct comprehensive psychosocial assessments for patients to identify emotional, social, financial, and environmental barriers impacting health outcomes.
Develop and implement individualized care plans to address identified needs, promoting access to medical, behavioral, and community support services.
Collaborate closely with Case Management, Nursing, and provider teams to coordinate care transitions and ensure continuity across inpatient, outpatient, and community settings.
Assist patients and families in understanding treatment plans, available health services, and eligibility for benefits, including Medicare, Medicaid, and community-based programs.
Provide short-term counseling, crisis intervention, and supportive therapy within the scope of practice to promote coping and adherence to care.
Coordinate referrals to behavioral health specialists, community agencies, and social service organizations to address complex psychosocial needs.
Participate in multidisciplinary team meetings to review care plans, identify high-risk patients, and support population health initiatives.
Document all interventions and communications accurately within the electronic health record (EHR), maintaining compliance with regulatory and organizational standards.

Benefits

Paid Time Off
Medical Insurance
Continuing Education
Professional Growth Opportunities
Mental Health Coverage
Trainings
Retirement 403b