• Collaborate closely with an interdisciplinary clinical team to deliver comprehensive, patient-centered palliative care to individuals with serious illness
• Conduct comprehensive assessments, including evaluation of psychosocial distress, mental health needs, caregiver burden, social determinants of health, and risk factors impacting patients with serious illness
• Clinically interpret assessment and screening results to identify priority needs, emerging risks, and appropriate interventions within the palliative care model
• Conduct serious illness conversations with patients and families and facilitate advance care planning conversations and documentation
• Provide clinical recommendations and escalation to physicians, advanced practice providers, and other clinicians in accordance with established escalation protocols, including concerns related to safety, mental health, caregiver stress, or complex psychosocial needs
• Develop, document, and contribute clinically appropriate interventions within individualized care plans, ensuring alignment with patient goals, values, and value-based care outcomes
• Participate in and contribute clinical insight during interdisciplinary rounds and case conferences, supporting coordinated, goal-aligned care and an optimal patient and family experience
• Deliver short-term clinical counseling, psychoeducation, and emotional support to patients and caregivers coping with serious illness, illness progression, and end-of-life considerations, within scope of LCSW licensure
• Serve as a clinical resource to the care team by identifying psychosocial barriers to care, recommending evidence-based interventions, and supporting transitions across care settings
• Utilize Tuesday Health’s electronic systems, tools, and technology to document clinical assessments, interventions, and care plans, supporting coordinated care delivery and quality measurement in a value-based environment
• Establish and maintain therapeutic, trust-based relationships with patients and families, grounded in clinical listening, empathy, and culturally responsive care
• Collaborate with the multidisciplinary team to improve quality of life, reduce avoidable utilization, and support holistic outcomes including appropriate and timely hospice transitions for members with serious illness
• Support the interdisciplinary team through care team debriefings following emotionally charged cases and the facilitation of periodic memorial rounds for the team
