CSS Caseworker

POSITION SUMMARY:

Under the direction of the Community Support Services Program Manager, the CSS Case Worker will provide community support/ case management services to the general patient population of APLA Health Center, Long Beach and APLA Health Center, CDU/MLK Medical Campus. The CSS Case Worker will be responsible for addressing the social determinants of health (SDOH) needs of our patients and ensuring that individuals are connected to appropriate health, social, and community services. The Case Worker will be expected to provide effective and culturally competent care and use various tools and approaches to support patient needs.

Community Support Services (CSS) is a new program that was started by APLA Health to better manage the SDOH needs of our general patient population. Case Worker will work collaboratively with medical, behavioral health, and administrative staff across each assigned clinic and build/maintain connections with external stakeholders in the community. The Case Worker will be able to participate in the development of this new program and inform the future of CSS. This is an exciting opportunity to create meaningful and multidisciplinary services that can empower patients to better manage and navigate chronic conditions, new diagnoses, and improve their social drivers of health.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

- Assess the SDOH needs of the general patient population and provides education in the following areas: chronic health conditions, behavioral health services, unmet health-related social needs, public assistance programs (Medi-Cal, Social Security Disability Insurance, Social Security Income, In-Home Support Services, food access, legal services, housing programs, etc.), and other resources available in the assigned health centers geographic area.

- Maintains a caseload of 60-80 patients. Caseload will be a combined mix of acuity and may be adjusted based on capacity of the Case Worker.

- Provides service throughout intake, case management, and follow-up.

- Maintains detailed records of patient interactions, assessments, referrals, interventions, and progress notes within the Electronic Health Record (EHR) and other CSS monitoring tools.

- Participates as an active member of the multidisciplinary team within assigned APLA Health Centers.

- Participates, as needed, in activities related to health centers and in collaboration with external stakeholders. For example: weekly Community Resource Groups for individuals with substance use disorder (SUD), city-wide community events, staff and community trainings, etc.

- Provides information for community resources, and as needed, conducts referrals and warm handoffs to community organizations, to best meet the needs of the patient.

- Conducts follow-ups with patients to ensure they have received quality care and were successfully referred to community organizations.

- Identifies, researches, and maps community assets to increase APLA Healths ability to meet patient needs.

OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.

Qualifications

REQUIREMENTS:

Training and Experience:

- BA/BS degree in Public Health, Social Work, Health Education, Nursing, Education or other related fields and 1 year of case management or care coordination experience OR Highschool diploma and 4 years of relevant case management or care coordination experience.

- Experience required must be in working with diverse and medically underserved populations including low-income adults, LGBTQ+ individuals, individuals with substance use disorder (SUD), and individuals impacted by trauma, stigma, housing instability, and systemic inequities.

- Ability to work collaboratively with internal and external stakeholders (medical and behavioral health staff, community-based organizations, etc.).

- Effective problem-solving and conflict-resolution skills.

- Strong communication skills.

- Current Cardiopulmonary Resuscitation (CPR) certification.

Knowledge of:

- Working with diverse and medically underserved populations including low-income adults, LGBTQ+ individuals, people living with HIV/AIDS, individuals with substance use disorder (SUD), and individuals impacted by trauma, stigma, housing instability, and systemic inequities.

- Basic medical terminology and patient care methods, techniques and healthcare background.

- Social Determinants of Health (SDOH) interventions.

- Motivational interviewing techniques.

- Outreach strategies and community engagement.

- Data collection, reporting, and basic data management.

- Microsoft 365 Suite (Outlook, Excel, PowerPoint, OneNote, etc.)

- Knowledge of local, county, state, and federal programs and resources for at-risk populations.

Ability to:

- Work independently with minimal direction.

- Work effectively with staff, volunteers and professionals.

- Be at ease and work with diverse groups (ethnicity, class, gender, sexual orientation).

- Engage in community/coalition building.

- Multitask and prioritize workload to maintain caseload requirements.

- Meet multiple deadlines in a rapidly changing environment.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS:

This is primarily an office position that requires only occasional bending, reaching, stooping, lifting and moving office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper.

SPECIAL REQUIREMENTS:

- Must possess a valid California drivers license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes.

- COVID vaccination and booster required or medical/religious exemption.

- Weekend/ evening work is required on occasion.

An EEO employer.