Integrated BH Clinician (LCSW​/APSW) – Primary Care

Location: Beloit, WI

Job :320

# of Openings:1

Job Title:

LCSW or APSW/Integrated BH Clinician

Department:

Medical/Integrated Care

EEO Category:
Professional

Exempt

Reports to:

Medical Director

The Licensed Clinical Social Worker (LCSW) / Integrated Behavioral Health Clinician provides behavioral health services, clinical social work support, and care coordination within the primary care setting. This role supports whole-person, patient-centered care by addressing behavioral health conditions, social determinants of health (SDOH), preventive care needs, and barriers to accessing medical and community services.

The clinician functions as an embedded member of the care team, working closely with medical providers, nursing, behavioral health staff, care coordination, referral staff, and community partners to improve access, engagement, follow-through, and health outcomes. Services include behavioral health assessment, brief intervention, short-term therapeutic support, crisis support, care coordination, and linkage to community resources.

This role includes active support of Wisconsin Well Woman Program and WISEWOMAN services, including patient outreach, education, follow-up, coordination of preventive care, cardiovascular risk reduction services, healthy behavior support services, and required program tracking. The position may also support obstetric (OB) care coordination depending on clinic workflow and staffing needs.

Services are delivered in a trauma-informed, culturally responsive, ethical, and patient-centered manner consistent with organizational policies, regulatory standards, professional scope of practice, and grant requirements.

• Provide integrated behavioral health services within the primary care setting, including assessment, brief intervention, short-term therapeutic support, and follow-up.
• Conduct behavioral health screenings and assessments; develop and implement short-term treatment plans within the scope of LCSW licensure and clinic workflow.
• Provide crisis intervention, safety planning, and risk assessment as clinically indicated.
• Identify and address social determinants of health through screening, assessment, care planning, and connection to appropriate community resources.
• Coordinate care across medical, behavioral health, social service, and community systems to support patient needs and continuity of care.
• Facilitate referrals and linkage to specialty mental health, substance use treatment, social services, and community-based programs when needs exceed the scope of brief integrated care.
• Perform warm handoffs with medical providers and participate in team-based care, case collaboration, and interdisciplinary care planning.
• Support Well Woman Program and WISEWOMAN services, including outreach, education, follow-up, coordination of preventive care, lifestyle intervention referrals, and cardiovascular risk reduction support.
• Assist with WISEWOMAN-related tracking, data collection, reporting, grant requirements, and quality improvement activities as required.
• Provide care coordination support for OB patients as applicable, including linkage to prenatal care, postpartum care, WIC, transportation, insurance resources, behavioral health services, and other supportive services.
• Document all patient encounters and care coordination activities accurately and timely in the electronic health record and other required systems.
• Promote patient engagement, adherence to care plans, preventive care completion, and improved health outcomes.
• Maintain confidentiality and comply with all legal, ethical, professional, and organizational standards.
• Participate in team meetings, case conferences, huddles, program meetings, and care coordination activities.
• Provide culturally responsive, trauma-informed care to diverse patient populations.
• Perform other related duties as assigned.

• Strong communication, organizational, follow-up, and documentation skills.
• Proficiency in electronic health record documentation.
• Ability to work independently and as part of an interdisciplinary team in a fast-paced environment.
• Commitment to mission-driven,…