Community-Based Social Worker (Cambria/Somerset Counties) – LSW, CSW, LPC

At ST Health Health Plan, every team member helps deliver Life Changing Medicine. We are hiring a full-time Mobile Professional Care Manager to join our Population Health team. In this role, you’ll work collaboratively with our Population Health Team to support members directly in their communities —helping them navigate challenges, access resources, and improve their overall well being.

What You’ll Do

• Provide in‑person and community‑based care management to ST Health Health Plan members across Cambria and Somerset counties (with occasional nearby travel).
• Complete holistic assessments focusing on behavioral health, physical health, social needs, and environmental factors.
• Coordinate member care across physicians, behavioral health providers, community agencies, and internal ST Health teams.
• Follow members in their homes, residences, and facilities to ensure they receive the support they need.
• Participate in occasional training and meetings in Pittsburgh.

Schedule

• Full-time, Monday–Friday
• Daylight hours: 8:00 AM – 4:30 PM
• Community based for in-home visits.
• Includes some remote work – which is a perk of this position!
   

Who We’re Looking For

• Licensed Social Workers (LSW/LCSW) or Licensed Professional Counselors (LPC). 

   

• Passion for helping individuals overcome barriers and supporting whole‑person health.

Why Join ST Health?

• Be part of a mission-driven organization making a tangible difference every day.
• Work independently while still having strong support from a collaborative team.
• Help shape the future of care management and community-based health.

Responsibilities:

• Conducts face-to-face member assessments by visiting the member in the member’s community, place of residence, or facility. Conduct on-site hospital coordination for discharge planning with facility staff if needed. Coordinate with member’s physicians to ensure follow-up and coordination of care
• Collaborates with providers and others in order to obtain initial assessment, treatment planning and aftercare planning for members.
• Conducts member assessments identifying behavioral, clinical, social, and environmental concerns and needs.
• Facilitates linkages for members and families between primary care and behavioral health providers and other social service or provider agencies as needed to develop and coordinate service plans.
• Ensures that cases are managed and documentation is within established timeframes in accordance with departmental standards. Participates in case conferences, interagency and provider treatment planning and departmental meetings.
• Makes referrals and provides expertise regarding community and governmental agencies.
• Assesses member’s knowledge of their clinical condition and the need for further education
• Implements appropriate clinical interventions to ensure optimal clinical and quality outcomes for members.
• Develops specific outreach plans for assigned members who do not maintain regular contact with their medical or behavioral health provider as recommended contributing to frequent crises, recidivism, and interfering with maximum benefit from available care.
• Receives and responds to complex and crisis calls.
• Coordinates care and services across the continuum of care with case management, physicians, pharmacy, behavioral health, and other providers or health plan departments as appropriate.
• Identifies barriers to care and develops specific integrated plan of care in collaboration with the member, family, provider, and ST Health Health Plan staff.
• Maintains contact with and refers members to community-based case management services as appropriate. Identifies provider issues and recommendations for improvement. Demonstrates knowledge of clinical treatment, case management and community resources.