Licensed Certified Social Worker

Maryland Primary Care Physicians, LLC

Department:
Primary Care/Population Health

Reports To:
Director, Population Health

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.

• 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.

• 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…