• Social Worker

    Job Locations US-RI-Smithfield
    Req No.
    Primary Care
    Regular Full-Time
  • Overview

    Works collaboratively with interdisciplinary Health@Home team to manage and coordinate care for a specific population of members whose needs represent high clinical, behavioral and social risk in order to ensure quality and cost-effective member-centered care.


    • Conducts home visits to evaluate, diagnose, and determine appropriate therapeutic clinical intervention arising from physical, environmental or emotional conditions. Responsibilities include 
      • Conducting comprehensive assessments
      • Developing care plans that consist of appropriate short and long-term goals related to behavioral health and social needs
      • Identify individual limitations, deficits, and strengths and aggressively attempt to provide patients with what they need in relation to medical, behavioral and social needs
    • Provides in home psychotherapy and counseling for patients as appropriate within the scope of practice for license
    • Coordinates and collaborates with local community Mental Health Centers, and any other BH provider, to facilitate, to implement, manage and monitor care plans as needed
    • Participates in rounds and case conferences with Health@Home team(s) to create an integrate plan of care that addresses behavioral health, medical and social service needs. Lead and model behavioral interventions to assist with chronic disease management
    • Identifies, provides/facilitates group or targeted coaching / training opportunities to support program/ patient/staff goals as they relate to behavioral health needs, including but not limited to motivational interviewing
    • Collaborates with manager to develop tools, audit performance and provided feedback regarding staff performance related to application of behavioral techniques/strategies.
    • Documents patient encounters and appropriately submits claims into the EMR within established timeframes.
    • Facilitates, manages and monitors referrals and coordinates needed services
    • Collaborates with Health@Home team, and other care managers at Neighborhood to identify needed services and supports
    • Serves as a clinical resource to respond to questions from the Health@Home team
    • Develop and maintain a list of recommended behavioral health screenings and processes to be utilized by team members, provide training to team and support correct, and consistent application of tools.
    • Communicates with ancillary departments, such as Provider Relations and Member Services, as necessary to meet individual needs of members and providers
    • Meets department and regulatory standards for accuracy, proficiency and documentation in order to communicate decisions and plan of care in an appropriate and timely manner
    • Takes responsibility for professional development, supports a learning environment and meets professional competency requirements
    • Participates in department continuous quality improvement activities
    • Provides cross-coverage as assigned by supervisor
    • Participates in outreach/marketing activities as needed and as appropriate
    • Other duties as assigned
    • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents



    • Independently Licensed MSW, with an active, current, unrestricted license in Rhode Island in good standing
    • Three (3) years’ experience in direct service
    • Experience working with the needs of individuals with behavioral health and/or long term chronic care needs
    • Intermediate skills in Microsoft Office (Word, Excel, Outlook)
    • Strong organizational and documentation skills
    • Excellent customer service orientation
    • Strong Interpersonal skills
    • Ability to travel for work, make home visits and must have access to reliable transportation and/or valid driver’s license and proof of insurance


    • Licensed Independent Clinical Social Worker ( LICSW ) with current active RI license in good standing
    • Clinical specialty experience , clinical specialty certification
    • Experience with treating addiction
    • Experience in clinical data review and reporting
    • Bilingual (English/Spanish)
    • Currently practicing within the scope of his/her license

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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