Complex Care Social Worker

The Social Worker in the Complex Care role supports individuals with high needs such as severe chronic illnesses functional limitations traumatic brain injury mental health and or comorbid substance use conditions significant social barriers (e.g. housing poverty criminal justice involvement) long- term care and guardianship cases. The CCSW is involved in managing complex high-risk cases with a focus on patient advocacy and reduction in patient length of stay and hospital readmission. The CCSW will perform biopsychosocial assessments manage care advocate for services and connect patients to resources to improve health outcomes and quality of life. The social worker partners closely with multidisciplinary teams to establish patient care needs and establish plans for discharge to the most appropriate level of care. The Complex Care Social Worker is an identified expert in mental health issues and provides consultation and educational programming to OHSU staff and the community.

Care Coordination:

• Navigating complex healthcare systems and bridging the gap between medical care and social circumstances. The social worker plays a crucial role in coordinating care across various services ensuring that patients receive comprehensive support. This includes liaising with healthcare providers therapists and other professionals involved in patient care.

Assessment & Care Planning:

• Evaluating social emotional and environmental factors affecting health to create individualized care plans and discharge needs. The CCSW will conduct assessments to identify the specific needs of clients and develop intervention plans that address both immediate and long- term patient care needs. The CCSW utilizes a person-centered approach considering the patients circumstances environment and support systems.

Clinical:

• The Complex Care Social Worker offers clinical expertise to medical providers when relevant to driving effective diagnosis and treatment of mental health substance use disorders and to provide basic medical care to those experiencing complex psychosocial barriers to discharge. CCSW are specialists in providing care for this vulnerable population. Use of therapeutic techniques by creating mutually agreed goals helps the patient enhance physical psychological and social functioning.

Therapeutic Support:

• The Complex Care Social Worker may deliver short- term therapeutic interventions during patient admission tailored to the unique needs of the patient particularly those with complex behaviors or multiple support needs. They work closely with families and care teams to develop effective strategies for managing these complexities.

Support for Families:

• In addition to working with patients the complex care social worker provides support for families helping them navigate the complexities of care and addressing any psychosocial issues that may arise.

Advocacy and Education:

• The social worker will advocate for patient needs within the healthcare system and educate families about available resources and support options. This may involve raising awareness about complex care issuesat both the individual and system levels.

Other duties as assigned

• A Masters Social Work (MSW) required.
• Certificate of Clinical Social Work Associate (CSWA) or Licensed Clinical Social Worker (LCSW) required for employees who practice clinical social work.

Job Related Knowledge Skills and Abilities (Competencies):

• Experience in behavioral health case management or medical settings.
• Provide counseling crisis intervention and coping strategies for patients and families facing for instance terminal illness or severe mental health crises.
• Ability to work in interprofessional teams.
• Strong advocacy skills.
• Knowledge of acute and ambulatory care models.
• Comprehensive Knowledge and understanding of the full scope of case management services and application across healthcare.
• Ability to work effectively with a team of healthcare professionals including patients caregivers nurses social workers and other practitioners.
• Ethical Treatment: Respect for patient autonomy confidentiality and informed consent.
• Obligations to document treatment accurately and limits information sharing.
• Personal and professional commitment to ethical practice including adherence to national and provincial laws governing specific professional activities.

• Health care experience preferred.
• 3 years working in a healthcare setting or providing acute mental health services care coordination and discharge planning.
• Bilingual language skill are strongly preferred

Posted: 5/12/2026 10:01am