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DaVita Medical Group Social Worker in Everett, Washington

Job Description

Job Title: Social Worker (PCT)

Supv Approval/Date:

Department: Personalized Care Team (PCT)

HR Approval/Date:

Job Code: 60

FLSA Status: EX

Grade: 14

EEO Code: 20

Reports To: Associate Medical Director

Tier: 0

JOB SUMMARY: Under minimal supervision, coordinate and provide information and resources about social service community programs to primarily meet the needs of our Medicare eligible patients and their families/caregivers, physicians and staff. Design strategies and implements social services that anticipates our Medicare patients and their families/caregiver needs to prevent social service crisis that lead to avoidable hospitalizations, facilitates discussions regarding advanced planning and end of life and improves quality of care and life.

ESSENTIAL DUTIES AND RESPONSIBILITIES: The duties listed below are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment.

60% Provides hands on social service support by:

  • Assessing patients/families/caregivers’ social service needs, developing written social services plan of care, following up with patient/family/caregiver and documenting in Epic.

  • Consulting in person and by phone with patients/families/caregivers, staff and providers on social service needs and concerns.

  • Linking patients/families/caregivers to community resources and facilitate interaction including information, referral to sources of financial assistance, transportation, food, housing and support groups.

  • Serving as a resource, which may include making presentations, to physicians and staff on community resources.

  • Acting as primary communicator to TEC physicians and staff about the social service programs available in the community.

  • Interfacing with patients/families/caregivers social service needs at the skilled nursing homes, hospitals, home health and hospice agencies.

  • Demonstrating an excellent knowledge of community resources in Snohomish County and how to identify resources in neighboring counties and the United States.

  • Meeting with patients and families in their home environment.

38% Mental Health Counselor

  • Support the mental and physical health care of patients on an assigned patient caseload. Closely coordinate care with the patient’s medical provider and, when appropriate, other mental health providers.

  • Screen and assess patients for common mental and health and substance abuse disorders. Facilitate patient engagement and follow-up care.

  • Provide patient and family education about common mental health and substance abuse disorders and the available treatment options.

  • Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.

  • Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.

  • Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated.

  • Facilitate referrals for clinically indicated services outside of the organization (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment).

  • Develops and coordinates a plan of care for the diagnosis, treatment, or referral of patients presenting moderate to severe social or mental behavior problems. Involves patient and/or family in treatment planning as appropriate.

  • Conducts individual, family or group therapy sessions based on ethical and medical necessity guidelines.

  • Provides a multi-disciplinary approach to plan of care by coordinating with other medical staff.

  • Administers plan of care, interviews and observes patients, and evaluates case histories. Monitors patients' adherence with medication plan.

  • Treats identified mental health diagnoses utilizing various psychological techniques and selects therapy.

  • Assesses patient progress and modifies treatment program accordingly.

  • Coordinates care of patients with referring physician or agencies.

  • Provide case management and/or long-term care for selected patients.

  • Documents therapy according to established procedures via an electronic medical record.

  • Intervenes as a crises counselor in situations requiring immediate psychological treatment.

  • Communicates with family to further the effectiveness of treatment program as allowed by law.

Duties listed below are integrated into all job functions:

  • All staff members are to promote a positive and productive work environment by acting maturely and responsibly, satisfactorily performing his or her job responsibilities and conducting themselves in a professional, courteous and respectful manner toward fellow employees, physicians and patients.

  • Must relate to other people beyond giving and receiving instructions: (a) get along with co-workers or peers without exhibiting behavioral extreme; (b) perform work activities requiring negotiating, instructing, supervising, persuading or speaking with others; and (c) respond openly and appropriately to feedback regarding performance from a supervisor.

  • Performs all duties in a manner which promotes and supports the Core Values and Compact of The Everett Clinic.

  • Integrates Lean principles, practices and tools to improve operational efficiency, reduce costs and increase customer satisfaction.

  • Frequently must follow written and oral instructions as well as complete routine tasks independently.

  • Completes annual compliance training on HIPAA/Privacy/Confidentiality/Non-Discrimination/Harassment/Integrity Statement and signs Agreements.

  • Ensures confidentiality of patient information following HIPAA guidelines and TEC policies.

  • Attends training to meet requirements of the job position and as needed or mandated by TEC policies, Div. of Occupational Safety & Health (DOSH), OSHA, L&I and other state/federal regulations.

  • Has regular and predictable attendance.


2% Other duties as assigned.


Knowledge, Skills & Abilities: Note that these requirements are representative, but not all-inclusive, of the knowledge, skill, and ability required to perform this job.

Knowledge: Knowledge of medical terminology.

Skills: Excellent interpersonal, oral, and written communication skills. Excellent customer service and analytical skills.

Abilities: Ability to be flexible and embrace change. Reads, speaks, understands and writes clearly in English. Works with initiative, energy and effectiveness in a fast-paced environment.

Education: Master’s degree in accredited social work educational program required.

Experience: Minimum 1 year of previous healthcare experience. Minimum 1 year of experience with geriatric patients preferred.

Certificate/License: Requires Licensed Independent Clinical Social Worker (LICSW).

Other: Driver’s license, reliable vehicle, and good driving record required.

PHYSICAL AND MENTAL DEMANDS: The physical and mental demands described here are representative of those that must be met by employees to successfully perform the essential functions of this job.


Must be able to frequently stand and move from place to place for long periods of time with intermittent breaks. Must be able to run during an emergency. Must be able to frequently use hands and fingers to handle, grasp or feel objects, tools, controls and medical or office equipment. Must be able to frequently repeat the same movements. Must be able to make quick, precise adjustments to machine controls and operate arms and legs quickly. Must be able to communicate clearly so listeners can understand and be able to understand the speech of another person. Must be able to hear sounds and recognize the difference between them. Must have a level of visual acuity to be able to detect details of objects from near and far and see differences between colors, shades and brightness and determine the distance between objects. May have periods of prolonged sitting in connection with telephone or computer usage. Must able to use muscles to lift, push, pull or carry heavy objects. Occasionally may be required to lift up to 50 pounds and carry up to 24 pounds. Must be able to bend, stretch, stoop, twist, squat, kneel, crawl, push/pull, grasp, handle or reach out. Must be able to operate two or more limbs together while remaining in place. Must be able to coordinate the movements of several parts of the body, such as arms and legs, while the body is moving. Must be able to demonstrate proper body mechanics to support physical activity for long periods without getting tired or out of breath. Must be able to keep or regain the body’s balance or stay upright when in an unstable position.


While performing the duties of this job, employees are regularly required to use written and oral communication skills; read and interpret data, information and documents; analyze and solve non-routine and complex office administrative problems; may use math and mathematical reasoning; observe and interpret situations; learn and apply new information or skills; perform highly detailed work on multiple, concurrent tasks; work under intensive deadlines with frequent interruptions; and interact with managers, staff, customers, patients, the public and others encountered in the course of work, some of whom may be dissatisfied or abusive individuals.

TYPICAL WORKING CONDITIONS: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Can involve dealing with sick patients. With frequent exposure to communicable/infectious diseases, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a clinic environment. Interaction with others is busy, constant and occasionally interruptive. Typical office conditions and noise level is usually quiet. Work may be demanding at times. May require ability to work irregular hours.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

CONTACT: Physicians, staff, patients, public and possibly vendors.

Job descriptions represent a general outline of job duties, functions and qualifications. They are not intended to be comprehensive in nature. In addition, jobs evolve over time and therefore their description may not reflect the precise nature of the position at a given point in time.