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 patient's 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.
REQUIREMENTS:
Training and Experience:
- A Master's 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 driver's 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.