At Diverge Health we are a team of entrepreneurs passionate about improving health access and outcomes for those most in need. We partner with primary care providers to improve the engagement and management of their Medicaid patients, providing independent practices access to specialized resources and clinical programs to address medical, social and behavioral patient needs. Our care ecosystem is equipped with enhanced technology and data interfaces to enable provider and patient success in a value-based environment. Guided by our core values of humility, continuous learning and feeling the weight, our team is on a mission to strengthen communities from within, unlocking people's ability to live their healthiest lives.
We are seeking a highly skilled and compassionate Collaborative Care Social Worker (LCSW or LMSW) to join our Ohio Team! This role will provide care in a primary care clinic, virtually, and community settings as needed. As a core member of our collaborative community care team, you will work closely with partner primary care physicians, a supervising psychiatric consultant, and our broader team in the field to ensure appropriate support for patients in need of behavioral health support.
What you'll Do
As a Social Worker at Diverge, your role will involve supporting and coordinating the mental health care of patients, ensuring collaboration with the primary care provider of assigned patients and the broader care team. Leveraging your clinical insight and connectedness to patients, creating connections across the broader mental health system when necessary to improve patient support and improvement.
Key areas you'll add value:
- Provide comprehensive social work interventions to patients and their families, including psychosocial assessment, brief individual or family counseling, advocacy, service linkage, referral, group work, case coordination, and long-term care planning and placement.
- Screen and assess patients for common mental health and substance abuse disorders; facilitate patient engagement and follow-up care.
- Provide patient education on common mental health and substance abuse disorders, as well as available treatment options.
- Systematically track treatment response and monitor patients for changes in clinical symptoms, treatment side effects, or complications.
- With a supervising Psychiatrist, Physician, or Nurse Practitioner, support psychotropic medication management, including monitoring treatment adherence, side effects, and treatment effectiveness.
- Utilize evidence-based techniques evidence-based techniques such as behavioral activation, problem-solving treatment, and motivational interviewing to support behavioral interventions.
- Facilitate referrals to evidence-based psychosocial treatments as clinically indicated.
- Participate in caseload consultation with the psychiatric consultant to review treatment plans and make recommendations for patients who require adjustments.
- Track patient follow-up and clinical outcomes using a registry system or electronic health record.
- Coordinate referrals for clinically indicated services outside the organization, such as social services, vocational rehabilitation, or substance abuse treatment.
- Develop relapse prevention self-management plans with patients who have achieved their treatment goals and are ready for discharge from the caseload.
What you Bring
- Minimum one (1) year of previous social work experience in behavioral health.
- Master's degree in social work (MSW).
- Active, unrestricted Licensed Independent Social Worker; License in Clinical Social Work* Ohio; or License Master Social Work*
- Training and/or experience in the Collaborative Care Model for integration of behavioral health in primary care.
- Demonstrated success working collaboratively as part of a multidisciplinary team providing patient support.
- Knowledge of social case management, conflict resolution, and team building practices.
- Adapts well to evolving technology including charting in an electronic record.
Preferred Qualifications:
- Two (2) years of experience post master's degree attainment.
- Care coordination experience in a managed care system, in-/outpatient setting, skilled nursing, or long-term care facility
- Fluency in Spanish
Personal Characteristics
- Strong interpersonal and communication skills, with the ability to collaborate effectively with Providers, care team members, and other stakeholders in the care ecosystem.
- Feels the weight- owners mentality, feels the weight of the lives we are impacting
- Continuous learner – curious, focus on ongoing improvement
- Humility- equally empathetic and objective, humble and highly conscientious; inspires partnership
Our Investors
Diverge Health is funded by GV and incubated by Triple Aim Partners, which since 2019 has partnered with entrepreneurs to co-found and launch eight companies focused on improving the quality, experience and total cost of healthcare.
At Diverge Health we believe that a diverse set of backgrounds and experiences enrich our teams and enable us to realize our mission. If you do not have experience in all areas detailed above, we encourage you to share your unique background with us and how it might be additive to our team.
Special Considerations
Diverge Health is dedicated to the principles of Diversity, Equity and Inclusion and Equal Employment Opportunities_ for all employees and applicants for employment. We do not _discriminate_ on the basis of race, color, religion, age, sex, national origin, disability status, genetics, protected _veteran_ status, sexual _orientation, gender identify_ or expression, or any other characteristic protected by the federal, state _or local_ laws. Our _decision_ to hire, promote, discipline, or discharge, will be based on merit, competence, performance and business needs._