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Blue Zones Health is a lifestyle-first well-being organization that partners with primary care providers and health plans to deliver whole-person care that improves outcomes, reduces unnecessary utilization, and supports patients beyond the four walls of the clinic. Our model integrates lifestyle medicine, health coaching, and social support to address the real drivers of health—especially social, behavioral, and environmental needs.

Position Summary

This is a foundational role for Blue Zones Health. The LCSW will provide 1:1 patient care navigation and SDOH support for patients while also designing, shaping, and scaling the LCSW capabilities in partnership with operations, product, and clinical leadership.

The ideal candidate is both deeply compassionate and systems-minded—someone who enjoys direct patient work and is excited to help build workflows, protocols, and best practices for a growing national program.

The compensation range for this role is $90,000 - $100,000 annually.

Key Responsibilities

Direct Patient Care & Navigation

• Provide 1:1 virtual support to patients via phone and video, focusing on:

Care navigation and coordination

SDOH assessment and intervention (housing, food access, transportation, financial stress, benefits)

Psychosocial support and problem-solving

Care transitions and follow-up

• Conduct structured assessments and develop individualized support plans.
• Connect patients to community-based resources, benefits, and services across diverse geographies, with an initial focus on supporting patients in California.
• Ensure closed loop communication and collaboration with primary care providers, care managers, Well-being Advisors (coaches), and other members of the care team.
• Document encounters clearly and accurately in HIPAA-compliant systems.

Practice & Service Design

• Help design and build the LCSW practice at Blue Zones Health from the ground up.
• Collaborate with Director of Well-being Services and Clinical Leadership to develop:

Intake and triage workflows

Scope-of-practice guidelines

Documentation standards and templates

Escalation and safety protocols

• Partner with Ops, Tech, and Clinical leadership to refine tools and workflows that support efficient, high-quality care delivery.
• Contribute to the development of playbooks, SOPs, and training materials for future LCSWs.
• Act as an ambassador to recruit, engage, and train network of LCSWs and other behavioral health professionals via thought leadership activities in public and written forums.

Clinical Quality & Compliance

• Ensure care delivery aligns with:

State licensure requirements

Ethical standards for clinical social work

HIPAA and organizational compliance policies

• Participate in clinical supervision, case reviews, and quality improvement efforts.
• Identify risk situations and follow appropriate escalation pathways.

Cross-Functional Collaboration

• Serve as the clinical voice for SDOH and care navigation in internal and external discussions.
• Provide feedback to product and operations teams on patient experience gaps and opportunities.
• Support partnerships with medical groups by aligning LCSW services to provider needs and workflows.

Required Qualifications

• Active LCSW license in at least California (multi-state licensure strongly preferred).
• 5+ years of experience providing clinical social work services in healthcare, primary care, or community-based settings.
• Deep experience addressing SDOH and care navigation (preference for experience supporting patients in California).
• Comfort working with patients across diverse geographies, cultures, and socioeconomic backgrounds.
• Strong documentation and organizational skills.
• Ability to work independently in a fully remote environment.
• Passion for whole-person, preventive, and lifestyle-oriented care models.
• Must be fluent in English and Spanish

Preferred Qualifications

• Experience working in value-based care, population health, or integrated care settings.
• Familiarity with virtual care delivery models.
• Experience helping design or scale clinical programs.
• Knowledge of care management or navigation billing frameworks (e.g., CCM, TCM, PCM).
• Multilingual skills. Spanish speaking preferred

What Success Looks Like

• Patients feel supported, empowered, and better able to navigate care and life challenges.
• Providers see the LCSW as a trusted extension of their care team.
• Clear, scalable workflows exist for LCSW services.
• The LCSW practice grows sustainably while maintaining high clinical quality.
• SDOH interventions translate into improved engagement and outcomes.

Employee shall comply with all applicable federal, state, and local laws, as well as all Employer policies, procedures, and standards, including but not limited to codes of conduct and ethics requirements, as amended from time to time.

For more information about Blue Zones Health, check us out at www.bluezoneshealth.com.

Blue Zones Health does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity or expression, age, disability, veteran status, or any other protected status under applicable law.