OHSU Internal Medicine Clinic (IMC) is large (92 providers), academic primary care practice that serves patients from the Portland Metro area, and across the State of Oregon. Our clinic delivers traditional primary care to over 13,000 unique adults per year, in addition to housing consult and specialty clinics that care for over 2,000 unique patients per year. These services include Oregon's only academic HIV practice, Oregon's only academic Geriatrics practice, and a robust Addiction Medicine practice that supports inpatient and outpatient care across OHSU.

 

The Social Worker is responsible for supporting and coordinating the mental and physical health care of CoCM patients on an assigned patient caseload with the patient’s primary care provider and the CoCM psychiatric consultant. When appropriate, the Social Worker may also coordinate care with other internal and external mental health providers.

 

This position involves a high degree of clinical complexity and advanced level of skill in delivering evidence-

based interventions targeted to improve wellbeing and health for a large variety of patients with emotional and

behavioral concerns commonly seen in a primary care setting. The work includes screening and assessing

patients for common mental health and substance use disorders, providing education about these conditions,

discussing available treatment options, and facilitating patient engagement and follow-up care.

 

The Social Worker also is responsible for systematically tracking treatment, engagement, and response (via a registry) and for monitoring patients (either in person, by phone or virtual visit) for changes in clinical status and treatment side effects or complications. The Social Worker supports the patient in their management of their psychotropic medication, focusing on treatment adherence monitoring, side effects and effectiveness of treatment. Additionally, the Social Worker provides brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving therapy, motivational interviewing, and other treatments as appropriate. The role also involves participation in regular (weekly) caseload consultation with the psychiatric consultantand communication of resulting treatment recommendations to the patient’s continuity medical provider. The Social Worker performs duties with minimal supervision. Work is reviewed for adherence to procedures, regulations, standards and for overall effectiveness. The Social Worker position is expected to serve as an advocate for collaborative behavioral health within the physical health care setting.

Counseling:

• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
• Support the patient in their 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.
• Support the mental and associated physical health care needs of patients on an assigned patient caseload. Closely coordinate care with the patient’s continuity medical provider and, when appropriate, other mental health providers.

Psychosocial Assessment:

• Screening and assessment of patients for common mental health and substance use disorders. Facilitate patient engagement and follow- up care.
• Provide patient education about common mental health and substance abuse disorders and the available treatment options.

Patient Services

• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications.
• Manage collaborative care registry.
• 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).
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care.
• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications.

Documentation:

• Document patient progress and treatment recommendations in the electronic health record (EHR) and other required systems to be shared with medical providers, psychiatric consultant, and other treating providers. 
• Track patient follow up and clinical outcomes using a registry. Document in-person and telehealth encounters in the registry and use the system to identify and re-engage patients.
• Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.

• A Master’s Social Work (MSW) required.  Health care experience preferred.

• Effective January 1, 2011, 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):

• Ability to utilize assessment information and collateral information to conceptualize patient psychopathology.
• Skill and expertise in conducting group and individual psycho-educational classes and brief, short-term therapy strategies that will help strengthen the patient's overall physical and mental health. 
• Incorporation of self-management, home-based practice in care planning.
• Skill in efficiently organizing time so that unscheduled, same day services are routinely available to care team members.
• The ability to exercise sound judgment in appraising situations and making decisions regarding complex physical and behavioral health treatment issues in consultation with the primary care teams.
• Skill in developing effective working relationships with peers, supervisors, and professionals in related disciplines.
• Ability to manage complex personal interactions.
• Demonstrated ability to act with minimal supervision on personal initiative using sound clinical judgment.
• Strong written and verbal communication skills. 
• Ability to maintain confidentiality regarding patient care information and chart contents as use of patient record and privacy of individuals must be protected to the fullest.
• Ability to maintain documentation in compliance with State, Federal, Professional and Ethical guidelines.

• Training in Primary Care Behavioral Health
• Health care experience
• Experience in behavioral health counseling and brief short-term therapy strategies and case management in an ambulatory setting.
• Experience and/or interest in Collaborative Care. 
• Experience in a Primary Care Ambulatory Clinic setting.
• Experience with program development and evaluation. 
• 3 years’ experience in similar position

Job Related Knowledge, Skills, and Abilities (Competencies):

• Knowledge of the principles and practices of behavioral health consultation, including assessment, diagnosis, treatment planning, cognitive-behavioral counseling strategies and their application to population-based care for preventive and chronic care issues.
• Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions for common mental health disorders, when appropriate (e.g., motivational interviewing, problem-solving treatment, behavioral activation).
• Comprehensive understanding of the interrelationship between medical and psychological systems and their impact on health.
• Experience in documenting clinical activities in a comprehensive, clear, concise fashion on a same day basis. 
• Basic knowledge of psychopharmacology for common mental health disorders

Posted: 5/29/2025 8:22am

 

Hours: Variable. Five 8-hour shifts, Monday-Friday, with possibility of evening or weekend hours. Flexing start/end times to accommodate clinical needs may provided, as well.

 

The work is performed in a medical setting and involves normal working hours with occasional alternative hours for special programs or outreach. The position involves interactions with people who have a wide variety of physical and behavioral health problems. Some travel may be required

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.