PSS Social Worker

POSITION SUMMARY:

Under the direction of the Program Manager, PSS/MCC, the Patient Support Services (PSS) Social Worker will provide the appropriate level of coordinated health care services for patients of APLA Health & Wellness. This position will focus on especially on APLA Health patients that have difficulty staying engaged in primary and HIV medical care due to psychosocial stressors including homelessness, post-traumatic response and other mental health challenges, and/or complicated medical co-morbidities. The PSS Social Worker will connect and engage patients primarily in clinical settings or, as needed, in their homes or elsewhere in the community. Using a Trauma-Informed lens, the PSS Social Worker will outreach and engage patients, complete screenings, link to APLA Health resources that patients may be eligible for and, as necessary, provide on-going assessment, case planning, and direct case management. The PSS Social Worker will provide services through the Division of HIV and STD prevention.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

- Help impacted patients navigate and link to APLA Health resources that they may be eligible for including, Benefits, Housing, and other HIV+ support services.

- Provide referrals, advocacy, and service information to patients, as needed.

- Use the Transtheoretical model of behavior change to support improved health outcomes for patients including treatment engagement and retention, medication adherence, risk reduction, and health provider communication.

- Maintain ongoing contact with patients and monitor progress related to goals set in the intervention plan.

- Coordinate and communicate among members of the patients care team including medical providers, mental health/addiction providers, allied health, community resources, and other team members. Participate in interdisciplinary case conferences for assigned case management patients.

- Document services in eClinicalWorks, e2LA, and/or other charting and data collection systems as appropriate. Documentation will be performed in a timely and accurate fashion in accordance with program policies and professional standards of care.

- Adhere to all applicable professional, legal, and ethical standards of behavioral health practice in the provision of services, including but not limited to: mandated reporting, provision of effective services, case documentation, patient confidentiality/HIPAA regulations, ensuring patient safety, and maintaining professional boundaries.

- Attend trainings and case conference meetings as required.

- Prepare monthly reports and statistics as requested.

- Effectively communicate with clients/patients in English and Spanish as required per aforementioned job duties.

OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.

Qualifications

REQUIREMENTS:

Training and Experience:

- A Masters Degree in Social Work, Counseling, Psychology, or related field from an accredited social work program.

- At least one year of experience providing care coordination or case management in either a clinical or a community-based setting.

- Specific training/experience working with people living with HIV/AIDS preferred.

- Experience in working with culturally diverse communities with the ability to be culturally sensitive and appropriate.

- Strong interpersonal skills and the ability to relate to individuals who may not share basic commonalities, including value systems and behavior norms.

- Ability to provide service to individuals with diverse economic, social, racial, and cultural backgrounds

Knowledge of:

- Interviewing and crisis management techniques

- Psychosocial and mental health factors affecting quality of life

- Data management;

- HIV/AIDS prevention, care and treatment, and substance use disorders

- Health education principles and program evaluation.

Ability to:

- Identify and implement outreach and engagement strategies

- Respond effectively to client crisis situations

- Interview and assess needs of clients

- Develop individual service plans aimed toward resolving client needs

- Communicate effectively, both written and verbally

- Work well under tight deadlines

- Coordinate multiple tasks

- Learn specific systems quickly and thoroughly

- Communicate effectively with a diverse population;

- Identify and update community resources;

- Proofread, edit and format written materials;

- Conduct group presentations, operate standard office equipment including Microsoft Office (Word, Excel, PowerPoint); and meet assigned deadlines.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS:

This is both a clinic-based and field-based position that requires only occasional bending, reaching, stooping, lifting and moving of 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 or medical/religious exemption.

Equal Opportunity Employer.