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 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.