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.