+ Works with the HealthStart team in identifying patients' psychosocial problems and develop care plans + Identifies and addresses barriers to care and navigation challenges across the care continuum y prioritizing health and SDOH needs. + Identifies and addresses gaps in internal and external resources, and sustainable connections to medical homes and sustainable social supports to improve the patient experience and achieve better outcomes + Provide psychosocial assessment, sustainable care transitions, and structured support to help address social and economic barriers to positive health outcomes and empower patients to set and achieve their individualized health goals. + Apply best practice interventions based upon care standards and referral and linkage to services to ensure behavioral and psychosocial needs are addressed, including but not limited to social needs, financial stressors, difficulty coping, behavioral health concerns or substance misuse, abuse and neglect, interpersonal violence, homelessness, functional decline, frequent ED visits or hospitalization, need for long-term care planning, etc. + Care coordination criteria, completes initial intake during enrollment visit, orientates patient to all services and coordinate/monitor delivery of service and referrals reinforce health education and provide support + Participate in performance improvement projects + Facilitates the resolution of crucial problems in the individual/family situation relating to recovery or management of the illness or disability through counseling services to patients and significant persons to the patient's life. + Criteria identifies and prioritizes areas for intervention and documents this information. provides related patient and family counseling and referrals around areas of dysfunction as appropriate. + Other tasks as required by manager, director, or leadership. Minimum Education and/or Experience Requirements* Education: Master's Degree in Social Work from an accredited school of social work required. Current LSW license in the state of New Jersey in good standing with the NJ Board of Social Work Examiners. Experience: + Behavioral Health or case management background preferred + 3-5 Year in Health related field, hospital experience preferred. + Strong knowledge of community resources and social services, financial, insurance, and advocacy system. + Familiarity with EPIC preferred. Licenses: + LSW license in the state of New Jersey in good standing with the NJ Board of Social Work Examiners. Other Desired Skills, Abilities, and Knowledge* Exceptional organizational and time management skills with the ability to multi-task, problem solve, and balance and deliver results in a program with multiple projects,programs and priorities.* Strong clinical, interpersonal, and analytical skills with clear verbal, telephonic and written communication.* Ability to function within an interdisciplinary team and develop and enhance collaborations with local community agencies and organizations.* Ability to navigate EMR and databases with demonstrated ability, including EMR documentation standards, Microsoft Office suite and metrics/outcome reporting.* Strong interpersonal and communication skills, problem solving, ability to work withdiverse populations, compassionate service delivery.* Bilingual (Spanish or Portuguese) At Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include: + Morristown Medical Center, Morristown, NJ + Overlook Medical Center, Summit, NJ + Newton Medical Center, Newton, NJ + Chilton Medical Center, Pompton Plains, NJ + Hackettstown Medical Center, Hackettstown, NJ + Goryeb Children's Hospital, Morristown, NJ + CentraState Healthcare System, Freehold, NJ + Atlantic Home Care and Hospice + Atlantic Mobile Health + Atlantic Rehabilitation We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners. We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades: + 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years + Best Places to Work in Healthcare - Modern Healthcare + 150 Top Places to work in Healthcare - Becker's Healthcare + 100 Accountable Care Organizations to Know - Becker's Hospital Review + Best Employers for Workers over 50 - AARP + Gold-Level "Well Workplace": Wellness Council of America (WELCOA) + One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine + One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine + Official Health Care Partner of the New York Jets + NJ Sustainable Business Named one of America's 50 Best Hospitals by Healthgrades, a World’s Best Hospital by Newsweek and recognized as a Best Regional Hospital in the NY Metro area by U.S. News & World Report. Our Atlantic Neuroscience Institute is the region’s leader in neuroscience care. A hub for the New Jersey Stroke Network, we offer a broad range of advanced neurological, neurosurgical and neurodiagnostic services. We are also certified as a Level IV Epilepsy Center and home to the Gerald J. Glasser Brain Tumor Center, where more brain tumor surgeries are performed than anywhere else in New Jersey. Our CyberKnife® program is the largest and most experienced in the state. We also have a satellite emergency department in Union, NJ, which treats about 40,000 emergency cases each year. Committed to providing exceptional care, Overlook Medical Center has achieved the prestigious Magnet® recognition. This designation from the American Nurses Credentialing Center is the highest national honor for nursing excellence. What’s more, Overlook Medical Center has advanced certification from The Joint Commission for perinatal care and is designated an Advanced Comprehensive Stroke Center. Additional Joint Commission-certified services include behavioral health care, spine surgery, wound care, and primary care medical home (PCMH). Atlantic Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted: Team Member Benefits + Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members) + Life & AD&D Insurance. + Short-Term and Long-Term Disability (with options to supplement) + 403(b) Retirement Plan: Employer match, additional non-elective contribution + PTO & Paid Sick Leave + Tuition Assistance, Advancement & Academic Advising + Parental, Adoption, Surrogacy Leave + Backup and On-Site Childcare + Well-Being Rewards + Employee Assistance Program (EAP) + Fertility Benefits, Healthy Pregnancy Program + Flexible Spending & Commuter Accounts + Pet, Home & Auto, Identity Theft and Legal Insurance ____________________________________________ Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer. EEO STATEMENT Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.