Social Worker

OHSU Internal Medicine Clinic (IMC) is large (92 providers) academic primary care practice that serves patients from the Portland Metro area and across the State of Oregon. Our clinic delivers traditional primary care to over 13000 unique adults per year in addition to housing consult and specialty clinics that care for over 2000 unique patients per year. These services include Oregons only academic HIV practice Oregons only academic Geriatrics practice and a robust Addiction Medicine practice that supports inpatient and outpatient care across OHSU.

The Social Workeris responsible for supporting and coordinating the mental and physical health care of CoCMpatients on an assigned patient caseload with the patients primary care provider and the CoCM psychiatricconsultant. When appropriate the Social Worker may also coordinate care with other internal and external mental health providers.

This position involves a high degree of clinical complexity and advanced level of skill in delivering evidence-

based interventions targeted to improve wellbeing and health for a large variety of patients with emotional and

behavioral concerns commonly seen in a primary care setting. The work includes screening and assessing

patients for common mental health and substance use disorders providing education about these conditions

discussing available treatment options and facilitating patient engagement and follow-up care.

The Social Worker also is responsible for systematically tracking treatment engagement and response (via a registry) and formonitoring patients (either in person by phone or virtual visit) for changes in clinical status and treatment sideeffects or complications. The Social Worker supports the patient in their management of their psychotropic medication focusing on treatment adherence monitoring side effects and effectiveness of treatment.Additionally the Social Worker provides brief behavioral interventions using evidence-based techniques such as behavioral activation problem-solving therapy motivational interviewing and other treatments as appropriate.The role also involves participation in regular (weekly) caseload consultation with the psychiatric consultantand communication of resulting treatment recommendations to the patients continuity medical provider.The Social Worker performs duties with minimal supervision. Work is reviewed for adherence to procedures regulations standards and for overall effectiveness. The Social Worker position is expected to serve as an advocate for collaborative behavioral health within the physical health care setting.

Counseling:

• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation problem-solving treatment motivational interviewing or other treatments asappropriate.
• Support the patient in their psychotropic medication management as prescribed by medical providers focusing on treatment adherencemonitoring side effects and effectiveness of treatment.
• Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment orbehavioral activation) as clinically indicated.
• Support the mental and associated physical health care needs of patients on an assigned patient caseload. Closely coordinate carewith the patients continuity medical provider and whenappropriate other mental health providers.

Psychosocial Assessment:

• Screening and assessment of patients for common mental health andsubstance use disorders. Facilitate patient engagement and follow-up care.
• Provide patient education about common mental health andsubstance abuse disorders and the available treatment options.

Patient Services

• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinicalsymptoms and treatment side effects or complications.
• Manage collaborative care registry.
• Facilitate referrals for clinically indicated services outside of the organization (e.g. social services such as housing assistancevocational rehabilitation mental health specialty care substanceabuse treatment).
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and thepsychiatric consultant and who may need more intensive or morespecialized mental health care.
• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinicalsymptoms and treatment side effects or complications.

Documentation:

• Document patient progress and treatment recommendations in the electronic health record (EHR) and other required systems to be shared with medical providers psychiatric consultant and other treating providers.
• Track patient follow up and clinical outcomes using a registry. Document in-person and telehealth encounters in the registry and use the system to identify and re-engage patients.
• Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.

• A Masters Social Work (MSW) required. Health care experience preferred.

• Effective January 1 2011 Certificate of Clinical Social Work Associate (CSWA) or Licensed Clinical Social Worker (LCSW) required for employees who practice clinical social work.

Job Related KnowledgeSkills and Abilities(Competencies):

• Ability to utilize assessment information and collateral information to conceptualize patient psychopathology.
• Skill and expertise in conducting group and individual psycho-educational classes and brief short-term therapy strategies that will help strengthen the patients overall physical and mental health.
• Incorporation of self-management home-based practice in care planning.
• Skill in efficiently organizing time so that unscheduled same day services are routinely available to care team members.
• The ability to exercise sound judgment in appraising situations and making decisions regarding complex physical and behavioral health treatment issues in consultation with the primary care teams.
• Skill in developing effective working relationships with peers supervisors and professionals in related disciplines.
• Ability to manage complex personal interactions.
• Demonstrated ability to act with minimal supervision on personal initiative using sound clinical judgment.
• Strong written and verbal communication skills.
• Ability to maintain confidentiality regarding patient care information and chart contents as use of patient record and privacy of individuals must be protected to the fullest.
• Ability to maintain documentation in compliance with State Federal Professional and Ethical guidelines.

• Training in Primary Care Behavioral Health
• Health care experience
• Experience in behavioral health counseling and brief short-term therapy strategies and case management in an ambulatory setting.
• Experience and/or interest in Collaborative Care.
• Experience in a Primary Care Ambulatory Clinic setting.
• Experience with program development and evaluation.
• 3 years experience in similar position

Job Related KnowledgeSkills and Abilities(Competencies):

• Knowledge of the principles and practices of behavioral health consultation including assessment diagnosis treatment planning cognitive-behavioral counseling strategies and their application to population-based care for preventive and chronic care issues.
• Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions for common mental health disorders when appropriate (e.g. motivational interviewing problem-solving treatment behavioral activation).
• Comprehensive understanding of the interrelationship between medical and psychological systems and their impact on health.
• Experience in documenting clinical activities in a comprehensive clear concise fashion on a same day basis.
• Basic knowledge of psychopharmacology for common mental health disorders

Posted:5/29/2025 8:22am

Hours: Variable. Five 8-hour shifts Monday-Friday with possibility of evening or weekend hours. Flexing start/end times to accommodate clinical needs may provided as well.

The work is performed in a medical setting and involves normal working hours with occasional alternativehours for special programs or outreach. The position involves interactions with people who have a widevariety of physical and behavioral health problems. Some travel may be required