VA - License Clinical Social Worker

The Licensed Clinical Social Worker (LCSW) Care Coordinator provides psychosocial support, care coordination, and advocacy for patients enrolled in the Ponos Care program. The role delivers patient-centered care through a hybrid environment that includes telehealth services and in-home patient visits within a 30-mile radius of Richmond, Virginia, collaborating with physicians, nurse practitioners, nurses, and other healthcare providers to address behavioral health needs and social determinants of health. Core duties include leading care coordination activities, developing comprehensive care plans, integrating medical, behavioral, and social services, providing counseling and emotional support, connecting patients with community resources, monitoring progress, conducting crisis intervention when needed, and supporting quality improvement initiatives. The position also involves program leadership, regulatory compliance with Virginia licensing and HIPAA, and maintaining accurate EHR documentation. A Master’s Degree in Social Work and an unrestricted Virginia license are required, with a minimum of three years of clinical social work experience; bilingual skills are a plus.