HealthPoint is a community-based, community-supported and community-governed network of non-profit health centers dedicated to providing expert, high-quality care to all who need it, regardless of circumstances. Founded in 1971, we believe that the quality of your health care should not depend on how much money you make, what language you speak or what your health is,because everyone deserves great care.

Position Summary:

The Social Worker I provides advanced biopsychosocial assessment, support, longitudinal care coordination and resource facilitation within an integrated interdisciplinary primary care team and provides peer and care team guidance as needed. The Social Worker I evaluates, engages, and serves a diverse population of patients with complex medical, behavioral health and social needs utilizing best practices, data, and continuous process improvement to provide the most equitable individualized care possible. This is an entry-level Social Work position with advancement opportunities.Compensation is dependent on skills and experience.

Your contribution to the team includes:

• Provide advanced biopsychosocial evaluation, assessment, triage, referral, and support to patients with complex medical, behavioral health and social needs by actively partnering with interdisciplinary care teams, focusing on overcoming social drivers of health and improving health equity. Develop, maintain, and advance individualized care plans with patients, focusing on individuals at high risk for poor health outcomes or avoidable high-cost care and actively facilitating achievement of health and wellness goals.
• Provide intake, longitudinal care management, and Social Work support to identified patients including behavioral health treatment planning, crisis intervention, transition of care support, resource navigation, community resource procurement, care coordination, emotional and short-term behavioral health support. Evaluate acuity of needs and assist patients in overcoming barriers to optimal health and wellness, promoting graduation from care coordination when appropriate and maintaining appropriate patient panel size.
• Provide advanced assessment and coordination of care for patients with complex behavioral health conditions or significant social challenges. Act as team and organizational resource providing Social Work expertise and perspective. Assist Supervisor with training and onboarding of peers, including mentoring and precepting.
• Actively maintain engaged patient panel utilizing proactive person-centered techniques and approaches such as critical thinking, motivational interviewing, case finding, SMART goal setting, health coaching, patient-empowerment, relationship-building and proactive independent collaboration. Work to improve health equity by identifying opportunities for system improvement, advocating for and implementing person-centered approaches to care.
• Be committed to a continuous learning environment where programmatic goals will shift based on the healthcare environment, requiring flexibility and prioritization. Provide advanced care coordination and Social Work support for patients in various programs including pilot projects, grant-funded initiatives or other populations as identified in collaboration with leadership. Travel to various locations including clinic, community, and home visits to provide care and support as needed.
• Actively partner with care team members to provide advanced psychosocial support and Social Work expertise especially for situations involving domestic violence, homelessness, trauma, substance use, crisis intervention, complex family dynamics, newly arrived refugees and other complex social or behavioral health situations. Promote patient self-management, self-determination, and person-centered care. Facilitate care conferences, identify needs, and connect to other interdisciplinary team members or specialties to support high quality patient care.
• Contribute to various practice and workforce development activities. Deliver presentations, education, and trainings as appropriate. Assist leadership with various duties such as: presentations, projects, research, program analysis, peer support, report facilitation, day to day operations. Provide peer support and case consultation. Support the review and updating of workflows or processes to ensure patient and staff safety.
• Effectively collaborate and establish new relationships with community partners and external organizations to promote health, wellness, effective coping and disease management of designated patient populations. Foster efficient delivery of care and services by assuring that effective communication exists between patients, their support system, and care teams. Respond to patient and care team requests promptly.
• Utilize the biopsychosocial perspective to administer and interpret screenings and assessments. Provide peer support and referrals for various risk factors or conditions to help guide and inform care plan and care support interventions or approaches such as PRAPARE, PHQ-9, GAD-7, KATZ, or PAM. Administer additional or advanced assessments as clinically appropriate. Assist with identification, evaluation, and implementation of new screening and assessment tools.
• For patients eligible for specific programs through their insurance carrier or public or private funders, including Health Homes or Medicaid, provide care and services in line with the requirements of the managed care organization, external entity, or funder. Complete any payer contract requirements including verification of patient eligibility, coordination of appointments, attending required trainings, administering and documenting screenings within required timeframes.
• Utilize patient-engagement skills to positively impact quality metrics, program, and clinical outcomes with designated patients. Be accountable for improving health outcomes, utilization rates, patient satisfaction, and self-sufficiency for a defined population of patients in alignment with evolving organization and population health goals for people with complex health and social situations.
• Maintain professional relationships and boundaries while supporting patients, families or caregivers with empathy, compassion and cultural congruence and maintaining respect for confidentiality, privacy, and mandated reporting.
• Identify and take appropriate action on patient safety situations, including assessing and facilitating patient safety planning, referrals and connections utilizing HealthPoint safety protocols, state and local guidelines. Utilize clinical judgment and leadership support to facilitate appropriate connection to direct care for patients in crisis when indicated.
• Maintain active patient engagement of appropriate caseload utilizing person-centered SMART goal setting, achievement, and individualized care coordination. Provide case consultation to HealthPoint colleagues for complex patient situations. Routinely reassess progress towards these goals, provide support to beneficiaries, and document accordingly in all necessary electronic systems.
• Effectively assess and utilize appropriate communication modalities to maintain consistent and timely connection with patients, families and care team members including phone calls, video visits, clinic or home visits, and electronic communications as appropriate.
• Act as a change agent to address health disparities, increase health equity and advocate for person-centered approaches to care.
• Identify opportunities and lead initiatives in population health approaches to patient care and support. Engage in data analysis and contribute to understanding health and social outcomes for patients, communities and within the care team. Perform analysis of situations, workflows, and outcomes as appropriate.
• Document appropriately and timely in electronic medical record, databases, and other electronic systems as indicated. Demonstrate efficient and effective approaches to managing workload.

Must have's you'll need to be successful:

• Master's Degree in Social Work and at least one (1) years of relevant work or clinical experience.
• Previous experience in a clinic or hospital setting, working with vulnerable populations, behavioral health or community health required.
• Bilingual language proficiency preferred.
• Valid Washington State Driver's License with an acceptable driving record determined by HealthPoint's insurance carrier.

Proof of vaccination for COVID-19 is required, prior to start. All new employees are also required to show proof of immunizations and/or immunity to MMR (measles, mumps, rubella), Varicella, Annual Influenza, and TB QuantiFERON Gold Titer. Additionally, if you work in a HealthPoint clinic, Tdap (within last 10 years) is required. Hepatitis B. is required for clinical employees with potential exposure to blood/blood products. All immunizations are a condition of employment. Upon hire, employees must provide proof of their immunizations and/or immune titer results prior to starting or no later than their fifth (5) business day of employment.

Where to gather your records:

• If you received immunizations in Washington, Arizona, Louisiana, Maryland or West Virginia, you may visit http://wa.myir.net to create an account and retain proof of your medical records for the immunity/immunization requirements.
• If records do not show any data, please seek guidance from your provider for further assistance.

HealthPoint is committed to offering all employees a competitive compensation package, including benefits and several other perks.

• Medical, Dental, and Vision for employees and their families/dependents
• HSA, FSA plans
• Life Insurance, AD&D and Disability Coverage
• Employee Assistance Program
• Wellness Program
• PTO Plan for full-time benefited and part-time benefited employees. 0-.99 years of service accrual of 5.23 hours per pay period. (pro-rated accruals for part-time benefited employees)
• Extended Illness Time Away of 40 hours (pro-rated for part-time benefited employees)
• 8 holidays and 3 floating holidays
• Compassion Time Away up to 40 hours
• Opportunity Time Off (extended time off for staff to invest in themselves) up to 8 weeks
• Retirement Plan with Employer Match
• Voluntary plans at a discount, such as life insurance, critical illness and accident insurance, identity theft insurance, and pet insurance.
• Third Party Perks Discounted Movie Tickets, Travel, Hotels, and more
• Development and Growth Opportunities

To learn more about HealthPoint, go towww.healthpointchc.org! #practiceyourpassion

It is the policy of HealthPoint to afford equal opportunity for employment to all individuals regardless of race, color, religion, sex (including pregnancy), age, national origin, marital status, military status, sexual orientation, because of sensory, physical, or mental disability, genetic information, gender identity or any other factor protected by local, state or federal law, and to prohibit harassment or retaliation based on any of these factors.