Social Worker - LCSW

About Us

We’re on a mission to change the way medical care is delivered around the country. By providing home‑based medical care to patients who need it most, Well Be is changing lives by delivering care wherever our patients call home. Well Be’s primary care services are delivered by licensed clinicians—including physicians, nurse practitioners, social workers, paramedics, and other healthcare professionals—offering an extra level of support to the patients we serve in their communities.

The high‑risk population we serve is typically underserved and challenged with access to care. To address these problems, we bring care to the patient, instead of trying to bring the patient to the care. Our clinician‑led geriatric care teams provide concierge‑level medical care and social support in the home, coordinating across the entire care continuum from chronic and urgent care to hospital, skilled nursing, assisted living, palliative care, and end‑of‑life care.

• Full‑time permanent position, primarily in the field seeing patients in their homes with a flexible schedule and on‑call rotation.
• Competitive total rewards package including health, dental, vision, life insurance, dependent care reimbursement, STD/LTD, 401(k) match with immediate vesting, paid time off, floating holidays, commuter reimbursement, and educational reimbursement.
• An opportunity to work with a progressive, mission‑driven company that is making a difference each day with every patient.

Our LCSWs are part of a team that provides compassionate care to the frailest elderly who have chronic and acute illnesses or injuries living in their homes. The LCSW delivers primary, urgent and acute care and counseling, connecting patients and families to support services, maintaining accurate patient records, and coordinating appointments as required. The successful candidate works as part of a team with physicians, advanced practice clinicians, and care team coordinators to deliver quality care to every patient.

• Practice the Well Be mission: help patients lead healthier, meaningful lives by delivering complete care.
• Perform psychosocial assessments and provide therapeutic services to patients and families.
• Work closely with the Behavioral Health Medical Director to manage complex patient cases and transitions of care.
• Serve as a resource for the community in managing complex behavioral health cases.
• Manage behavioral and psychosocial needs that result in improved clinical and financial outcomes.
• Maintain constant communication with patients, addressing concerns and goals to keep positive attitudes.
• Build rapport with patients and families and relay concerns to Well Be providers/IDT.
• Assist members in effectively utilizing available resources to meet personal health goals and develop capabilities.
• Monitor patient progress and adjust treatment plans as needed.
• Coordinate with healthcare providers, agencies, and community resources to create thorough treatment plans addressing social, cultural, and financial needs.
• Collaborate with the interdisciplinary team and participate in regular team meetings.
• Ensure compliance with regulatory agencies and Well Be clinical guidelines.
• Partner with the community to refer patients to appropriate low‑cost services (e.g., Meals on Wheels, AAA, Senior & Assistance Programs, transportation resources).
• Involve patients’ families and primary caregivers in achieving the best care decisions and outcomes.
• Collaborate with all involved parties—including health services contractors—to meet patient care goals.
• Consult with and advise the Clinical Team on the social, emotional, and cultural factors affecting health and care.
• Comply with safety policies and report unsafe acts or conditions to supervisors or team.
• Consistently meet or exceed Well Be productivity, customer service, quality, and performance targets.
• Participate in community activities that link Well Be to its communities.
• Maintain current written progress notes and other documentation on the member Medical Record, including signed and dated documentation for all services provided.
• Participate in program and policy development of the…