Clinical Social Worker

OverviewHarmonyCares is a leading national value-based provider of in-home primary care services for people with complex healthcare needs. Headquartered out of Troy, Michigan, HarmonyCares operates home-based primary care practices in 14 states. HarmonyCares employs more than 200+ primary care providers to deliver patient-centered care under an integrated, team-based, physician-driven model. Our Mission – To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Our Shared Vision – Every patient deserves access to quality healthcare. Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other. Why You Should Want to Work with UsQuarterly Bonuses – up to $5000 per year!Health, Dental, Vision, Disability & Life Insurance, and much more401K Retirement Plan (with company match)Tuition, Professional License and Certification ReimbursementPaid Time Off, Holidays and Volunteer TimePaid Orientation and TrainingDay Time Hours (no holidays/weekends)Great Place to Work CertifiedEstablished in 11 statesLargest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today! More details about the benefits we offer can be found at ResponsibilitiesThe Clinical Social Worker is an integral member of the care team and contributes to the care coordination for patients with multiple social stressors and/or behavioral health concerns.  The Clinical Social Worker utilizes screening criteria for the coordination of quality health care services, reduction of service fragmentation, enhancement of quality of life, and the appropriate use of healthcare and community resources. Essential Duties and ResponsibilitiesManage a caseload of high-risk socially complex patients Conduct face to face and telephonic psychosocial assessments with the patient and/or the caregiver Investigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needs Provide short-term counseling services as neededCoordinate services to ensure the patient/family understands a treatment planWork as part of a collaborative care team to achieve optimal quality and patient experience outcomes, including being an active member in High-Risk HuddlesProvide outreach to community-based services to support the patient’s ability to age at homeDevelop and implement shared goals of care with the patient and familyWork with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independenceIn this role you may work with. . .ProvidersSupport staffCare TeamPatientsPatient FamiliesCaregiversFacilities3rd party entities External ProvidersCommunity Resources QualificationsRequired Knowledge, Skills and Experience Master’s degree in social workMust be licensed as an LCSW or LISW (depending upon state)Must maintain a valid driver’s license and good driving record The ability to use sound clinical judgment and communicate clearly in both written and verbal formatsAbove average computer skills Ability to be self-directed and able to communicate effectively with professional staff across many disciplines and programsMust have the ability to plan time effectively, balance multiple tasks, work within stringent time frames, resolve problems, identify patient service trends, determine system improvements, and implement changeAbility to share expertise with others and demonstrates an understanding of the need to foster performance improvement while achieving patient satisfaction and efficiencyPreferred Knowledge, Skills and Experience Experience in Care Management in community-based setting or equivalentExperience working with the chronic, complex and/or behavioral health population Pay Transparency Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations.

Created: 2025-12-02