Hometown Health Center | ME, United States

Posted Date 4/29/2022


The Licensed Social Worker (LSW) reports to the Project Coordinator and is responsible for supporting the patient and assisting with connection to resources based upon needs assessment and social determinants of health. The Licensed Social Worker will complete and maintain accurate records and reports regarding the patient histories and progress, services provided, and other required information. The LSW will screen admissions for high risk patients who may require social service intervention. The LSW will demonstrate the mission, vision, and values of HOMETOWN Health Center (HHC) in the health center and in the communities that we serve.


  • Utilize tools in real-time, such as the PRAPARE and other reports from the electronic health record to recognize or initiate patient engagement.
  • Assess patient’s Social Determinant of Health (SDOH) and documents in electronic health record
  • Review and evaluate patient’s progress in relation to measurable goals described in treatment and care plans.
  • Modify treatment plans to reflect with changes in patient status.
  • Assist patients and families to fully utilize community resources.
  • Assist patients and families to develop goals based upon needs and treatment plans.
  • Participate in case conferences and staff meetings.
  • Act as liaison between patients and internal resources to include Community Health Worker, Care management and Behavioral Health.
  • Coordinates discharge planning and facilities discharge planning rounds.
  • Counsels patient/family to achieve optimal level of psychosocial functioning.
  • Follows progress of discharged patients in order to determine effectiveness of treatments.
  • Responds to crisis situations such as child abuse and mental health emergencies and follow’s HHC policy.
  • Participates in all safety program training, drills and education sessions AND may include assignment to an emergency response team.


Performs other duties as assigned.


  • Strong organizational skills with the ability to handle multiple priorities while remaining professional and calm.
  • Ability to work with many diverse people.
  • Effective telephone and communication skills.
  • Maintain high level of confidentiality due to the sensitivity of materials and information handled.
  • Ability to make suggestions on workflow or system efficiency and effectiveness.
  • Ability to work independently, be self-directed and flexible.
  • Ability to prioritize, perform functions with minimal supervision, and work in a fast-paced environment.
  • Ability to perform at a high level of accuracy with attention to detail.
  • Complete documentation in a timely manner.


  • Be committed to the mission of the Hometown Health Center.
  • Behave in a professional manner and consistently demonstrate and promote the values of respect, honesty, and dignity for the patient, families, and all members of the healthcare team.
  • Committed to the constant pursuit of excellence and teamwork in improving the care of the patient and families of Hometown Health Center and the Patient Centered Medical Home Neighborhood.
  • Be punctual for scheduled work and use time appropriately.
  • Perform duties in a conscientious, cooperative manner.
  • Perform required amount of work in a timely fashion with a minimum of errors.
  • Be neat and maintain a professional appearance.
  • Maintain confidentiality and protect the Practice by abiding by laws and principles related to confidentiality; keep information concerning Practice Operations, patients and employees confidential.
  • This position requires compliance with Health Center’s compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of the Clerical Data Entry Specialist’s regular performance evaluation.
  • Adheres to Hometown Health Center’s Employee Immunization policy.


The physical requirements described here are representative of those that must be met by the Incumbent to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the job, duties may include bending, sitting, standing, walking, reaching. May also require lifting of patients and at times long hours. This position requires the ability to deal with stressful situations and crises; mentally demanding. Eye and hand coordination required.


The work environment characteristics described here are representative of those the incumbent encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work presents potential exposure to infection, blood and other body fluids – must follow proper protective precautions. Exposure to drugs and narcotics, and other possible chemicals possible.


Experience and Skill Requirements: The following experience and skills are considered essential:

  • Ability to make referrals to internal resources and Community Agencies (when & how).
  • Ability to identify patients in crisis and act swiftly to assist.
  • Ability to maintain ongoing communication with patients, families, physicians, customers, and other interested parties (DHHS, APS, CPS, etc.)
  • Complete electronic chart documentation timely.
  • Knowledge of advance directive forms and legal lines of decision-making authority.
  • Knowledge of high-risk screening criteria.
  • Knowledge of Federal and State guidelines pertaining to all work areas.
  • Knowledge of medical conditions and impact on patient care needs.
  • Knowledge of SDOH and PRAPARE tool.

Education Requirements: The following education requirements are considered essential:

Bachelor’s Degree in Social Work or a related field.

Social Work license in the State of ME.

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