Clinicalsocialworkassociation

Maryland Primary Care Physicians, LLC

Department: Primary Care/Population Health

Reports To: Director, Population Health

Position Summary

Maryland Primary Care Physicians (MPCP) is seeking a compassionate, patient-centered Licensed Clinical Social Worker (LCSW-C) to join our Population Health and Integrated Behavioral Health team. This role supports patients within a collaborative primary care environment by addressing psychosocial, behavioral, and social determinants of health that impact overall wellness, healthcare utilization, and clinical outcomes.

The Licensed Clinical Social Worker will provide behavioral health interventions, care coordination, case management, patient advocacy, and resource navigation services through telephonic outreach and in-office patient visits. The position plays a key role in MPCP’s population health initiatives by supporting high-risk and medically complex patients, reducing barriers to care, improving care coordination, and promoting preventive and value-based healthcare strategies. The ideal candidate is skilled in collaborative care, patient engagement, interdisciplinary communication, and population health management, with a strong commitment to improving patient well-being and health outcomes.

Key Responsibilities Clinical Care & Patient Support:

• Utilize validated, evidence-based assessment tools (e.g., PHQ-9, GAD-7, AUDIT/DAST, C-SSRS, PRAPARE) to identify behavioral health concerns, social needs, and barriers to care.
• Utilize evidence-based social work practices (such as brief Cognitive Behavioral Therapy, Motivational Interviewing, Problem-Solving Therapy, Behavioral Activation, and SBIRT) to identify and implement person-centered/individualized treatment goals.
• Provide brief interventions, counseling support, suicide and self-harm risk assessment, safety planning, crisis intervention, and ongoing case management services, including coordination with crisis teams and emergency services when indicated.
• Assess the impact of social determinants of health and connect patients with appropriate community resources and support services, including assistance with insurance and benefits navigation (Maryland Medicaid, Medicare, marketplace plans), prescription assistance programs, and disability or leave paperwork (e.g., FMLA, short-term disability).
• Engage and motivate patients to participate in treatment planning in collaboration with primary care providers and care teams.
• Identify patients who may benefit from higher levels of behavioral health or substance use treatment and facilitate referrals as clinically appropriate.
• Provide real-time warm handoffs and same-day behavioral health consultations during primary care visits when a provider identifies an acute behavioral health or psychosocial concern.
• Support advance care planning conversations, including assistance with advance directives, MOLST forms, caregiver support, and referrals to palliative care or hospice when appropriate.
• Provide behavioral health consultation and capacity-building support to primary care providers and clinical staff, including coaching on screening practices, brief interventions, motivational interviewing, and effective referral pathways.
• Support patients across populations commonly served in primary care, including those with comorbid behavioral health and chronic medical conditions (e.g., diabetes, CHF, COPD), anxiety concerns, geriatric and cognitive concerns, and post-hospital-discharge transitions.

Care Coordination, Population Health & Collaboration:

• Serve as an active member of the interdisciplinary primary care and population health team to support coordinated, patient-centered care.
• Identify and support high-risk, high-utilization, and medically complex patients through targeted outreach and care management interventions.
• Collaborate with primary care providers, managers, and other healthcare professionals to optimize patient outcomes and improve quality metrics, including HEDIS, MIPS, and value-based care measures such as depression screening and follow-up, unhealthy alcohol use screening, follow-up after ED visits for mental illness, and initiation/engagement of substance use disorder treatment.
• Support population health initiatives focused on preventive care, chronic disease management, behavioral health integration, care transitions, and reducing avoidable healthcare utilization.
• Support post-discharge follow-up and Transitional Care Management (TCM) workflows for patients recently discharged from hospital or emergency department settings, including timely outreach within 7, 14, and 30 days as appropriate.
• Develop and maintain an up-to-date network of external referral resources, including community mental health centers, substance use treatment providers, food and housing assistance, transportation services, and Maryland-based public benefit programs.
• Support Collaborative Care Model (CoCM) and Behavioral Health Integration (BHI) workflows as applicable, including documentation and care management activities that support associated billing and quality reporting requirements.
• Utilize available data, registries, and reporting tools to assist in identifying gaps in care and patient needs.
• Communicate patient progress, barriers, and interventions through the electronic medical record and interdisciplinary team meetings.
• Participate in integrated care initiatives and value-based care programs designed to improve behavioral health outcomes, patient engagement, and overall population health performance.

Documentation & Compliance:

• Complete accurate, timely, and compliant documentation within the electronic medical record.
• Maintain confidentiality and uphold ethci standards in accordance with HIPAA, 42 CFR Part 2 (substance use disorder records), professional social work practices (NASW Code of Ethics), and organizational policies.
• Assist with the development and implementation of departmental policies, protocols, and workflows as requested.
• Perform additional duties and responsibilities as assigned.

Qualifications Education & Licensure

• Master’s Degree in Social Work (MSW) from an accredited program required.
• Active Licensed Certified Social Worker – Clinical (LCSW-C) license in the State of Maryland required.
• Candidates with an active Licensed Master Social Worker (LMSW) license who are in the process of obtaining LCSW-C licensure may also be considered.

Experience

• Minimum of two (2) years of supervised clinical social work experience preferred.
• Experience in integrated healthcare, primary care, behavioral health, or medical settings preferred.
• Experience coordinating care, training staff, or supporting interdisciplinary teams is a plus.

Knowledge, Skills & Abilities

• Strong understanding of behavioral health, case management, population health principles, and social determinants of health.
• Excellent interpersonal, communication, and patient engagement skills.
• Ability to work collaboratively within a multidisciplinary healthcare team.
• Strong organizational skills with the ability to manage multiple priorities effectively.
• Proficiency with electronic medical records and population health tools (e.g., Epic, Care Management Platforms).
• Commitment to patient-centered, culturally competent care.
• Bilingual proficiency (Spanish/English) preferred.
• Working knowledge of HIPAA, 42 CFR Part 2, and Maryland-specific behavioral health and social services regulations.

Work Environment & Physical Requiremen ts

• Work is primarily performed in an office or clinical environment with frequent interaction with patients and healthcare staff.
• Position may include telephonic patient outreach and in-office patient visits, with potential travel between MPCP practice locations across Maryland. Telehealth coverage across practice sites may be required.
• Requires prolonged periods of sitting, occasional standing, stooping, and stretching.
• May occasionally lift or move up to 30 pounds.
• Requires manual dexterity and visual/hearing acuity sufficient to operate office equipment and communicate effectively.