PRIMARY FUNCTIONS: As part of an interdisciplinary team within a community health center this position is responsible for assessing client needs across multiple areas including barriers to accessing basic and specialty medical and behavioral health care. The FSW provides information, referral and case management support for patients of the health center; identifies available community resources and assists in determining eligibility; coordinates and distributes resources for specialty community resource programs; provides opportunities for patients to learn skills to foster greater independence and self-sufficiency. The FSW participates in implementation of processes to ensure universal health screenings are completed across the organization and may serve as an SBIRT champion at the site level, ensuring that patients with risky substance use behaviors receive interventions while in the clinic.

Demonstrates a sincere dedication and loyalty to the philosophy and mission of Neighborhood Health.

DUTIES/ RESPONSIBILITIES: (Essential Functions: Duties and responsibilities noted with bullets are considered to be the essential functions of the job)

• Meets individually with patients to provide a variety of services including support with obtaining financial assistance for medical bills, coordinating transportation to specialty care appointments, and assisting patients with scheduling specialty appointments, interpretation/translation, while providing opportunities for patients to develop and strengthen these skills and increase self-sufficiency.
• Supports integrated primary care behavioral health initiative by providing targeted case management under the direction of behavioral health and medical providers to reinforce specific behavior modification plans through telephone encounters as well as facilitating referrals of patients to specialty medical and behavioral health services when needs are identified.
• Provides targeted case management for patients with chronic illness experiencing barriers to achieving health and wellness goals.
• Provides administrative support for behavioral therapists including scanning of patient documents, obtaining treatment records and assisting patients in obtaining behavioral health appointments as needed.
• Ensures universal health screening process is completed at assigned clinic sites and assist in process improvement plans as need.
• Responds to the needs of patients demonstrating risky substance use behaviors using SBIRT model.
• Serves as a resource to clinical team and providers in the treatment of substance use disorders.
• Maintains an updated database of community resources (e.g., financial assistance, food, clothing, employment, shelter/housing, etc.) and periodically updates clinical team members on availability of resources.
• Collaborates with medical providers, nursing staff and referral coordinators in assisting patients with complex medical needs to obtain needed services, including translation of patient education materials and instructions for hospital procedures.
• Establishes and maintains strong working relationships with community partners to facilitate access to resources such as food banks, clothing programs, financial and charity programs.

• Manages the distribution of annual specialty services such as coat drives, turkey distribution and other services as available.
• Documents all services in the electronic medical record, in accordance with organization’s standards.
• Responds to all communication, both internal and external, in a timely manner.
• Provides coverage for other caseloads when needed.
• Maintains records according to established guidelines.
• Attends and participates in Department and organization meetings by sharing knowledge, experiences, and information regarding team members, clients, work practices, etc.
• May participate in agency workgroups and/or teams.
• Attends and participates in on-going training, learning and growth opportunities.
• Maintains policy manuals incorporating changes when received.
• Attends all staff meetings.
• Attends relevant continuing education events and training as identified and approved by supervisor.

OTHER DUTIES:

• Prepare and maintain special internal and external reports as requested by Supervisor and/or Department Head.
• Assist with developing, coordinating and recommending changes for the improvement of workflow in the program or section area.
• May be assigned to various project lead roles to advance the development of the department and support ad hoc needs.
• Able to work under minimal supervision.
• Employee will be asked to perform additional duties and take on other responsibilities as dictated by events and circumstances.

QUALIFICATION/EDUCATION and/or EXPERIENCE REQUIREMENTS:

• Associate Degree and/or higher education preferred.
• 2-3 years direct experience working in a community-based setting providing case management or other enabling services.
• Strong skills in building patient rapport, time management, organization and attention to detail. 
• Experience in a Patient Centered Medical Home setting is strongly preferred.
• Excellent interpersonal communication skills and the ability to work effectively with a diverse work force and client base.
• Proficient with Microsoft Windows and Microsoft Office, including Word and Excel.
• Self-disciplined, mature, independent, outstanding oral and written communication skills.
• Must be able to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations.
• Must be comfortable working with culturally diverse populations.
• Demonstrate superior critical thinking skills, sound judgment, and decision-making and problem-solving skills.
• Knowledge of local health care environment and basic terminology.

Fluency in Spanish required.