Lead Social Worker - Palliative Care and Population Health

We are currently seeking a highly motivated Lead Social Worker, Palliative Care & Population Health. This role will report to the Regional Chief Medical Officer and enable us to continue to scale in the healthcare industry.

The Lead Social Worker will provide both direct patient care and program leadership for Astrana Health's Population Health, Care at Home, and Palliative Care programs. This individual will support patients and families with complex psychosocial needs while leading social work program development, staff mentorship, advance care planning initiatives, quality improvement efforts, and interdisciplinary care coordination.

What You'll Do

Clinical Responsibilities
• Completes introductory home visit to Care at Home patients in need of Palliative Care services, advance directives completion and transition to higher level of care as appropriate.
• Assesses the psychosocial status of members and families/caregivers related to the member's mental conditions and environment and communicates findings to the other members of the interdisciplinary group.
• Provides an in-home assessment of member's psychosocial and living status and assistance when it is not safe for the member and another plan is required.
• Customarily and regularly exercises discretion and independent judgment in the performance of duties.
• Carries out social evaluations and plans intervention based on evaluation findings.
• Counsel patients and families/caregivers as needed regarding stress, anxiety, illness adjustment, grief, and other identified coping difficulties.
Maintains clinical records on all patients referred to social work.
• Provides information and referral services for organization patients and families/caregivers regarding practical and environmental needs.
• Provides information to patients and families/caregivers and community agencies.
• Serves as liaison between patients and families/caregivers and community agencies.
• Maintains collaborative relationships with organization personnel to support patient care.
• Maintains and develops contacts with public and private agencies as resources for patients and personnel.
• Participates in the development of individualized plans of care and attends regularly scheduled interdisciplinary group meetings.
• Educates physicians and other team members regarding significant social and emotional factors related to health problems and end-of-life issues.
• Actively participates in quality assessment and performance improvement activities.
• Manages the assessment and delivery of counseling services to ensure timely and appropriate services for family/caregivers.
• Plans for Palliative Care Program development, expansion and refinement through annual evaluation of services.
• Functions independently while seeking and accepting guidance from members of the interdisciplinary group and community resources.
• Performs other duties as delegated by Population Health leadership.

Leadership & Program Development Responsibilities
• Serve as the lead social work resource for Astrana Health's Population Health, Care at Home, and Palliative Care programs in Texas.
• Develop, implement, and maintain social-work workflows, protocols, standard operating procedures, and best practices.
• Develop and update training materials, tools, and educational resources for social workers.
• Train, mentor, and provide ongoing support to social workers and interdisciplinary team members.
• Provide consultation and guidance on complex psychosocial, behavioral health, palliative care, and social determinant of health cases.
• Lead Advance Care Planning (ACP) initiatives, including education, process development, documentation standards, and auditing activities.
• Facilitate patient and family discussions regarding goals of care, advance directives, and transitions of care.
Collaborate with physicians, case managers, behavioral health providers, and community organizations to improve care coordination and outcomes.
• Assist with development, implementation, expansion, and evaluation of palliative care services.
• Participate in quality improvement, utilization management, and performance initiatives.
• Support regulatory readiness, accreditation activities, and compliance requirements.
• Monitor program outcomes and social work quality metrics.
• Travel within service areas to support program implementation, training, and operational needs.

Qualifications

Required:
• Master's Degree in Social Work.
• Meets personnel qualifications stated in
• Active social work licensure as required by applicable state regulations.
• Minimum 7+ years of clinical social work experience, preferably in palliative care, hospice, home-based care, population health, managed care, or complex case management.
• Minimum 2 years of leadership, mentoring, training, supervisory, or program development experience.
• Demonstrated ability to supervise and direct professional and administrative personnel.
• Ability to deal tactfully with patients, families and the community.
• Knowledge of corporate business management, governmental regulations, CMS requirements, and Joint Commission standards.
• Demonstrates good communication and public relations skills.
• Demonstrates autonomy, organization, assertiveness, flexibility, and cooperation.
• Must have clinical experience relevant to the psychosocial needs of patients and families.
• Ability to drive to patient homes.
• Valid driver's license.

Preferred:
• LCSW.
• Hospice, palliative care, supportive care, or serious illness management experience.
• Experience developing workflows, training programs, and quality improvement initiatives.
• Experience auditing documentation and coaching clinical staff.
• Bilingual English/Spanish preferred.

Environmental Job Requirements and Working Conditions

- This is a full-time position.
- This position requires traveling to patient homes throughout Houston.
- The national target compensation for this position is $65,000 - $81,000 per year. Actual compensation will be determined based on geographic location (current or future), qualifications, and other job-related factors.