What are the responsibilities and job description for the Social Worker position at Delta Health Alliance?
The Licensed Social Worker / Behavioral Health & Community Resource Coordinator is responsible for providing social work services, behavioral health support, care coordination, and community resource navigation for patients served by the FQHC.
- Conduct psychosocial assessments to identify patient needs, barriers to care, and social determinants of health.
- Provide short-term counseling, crisis intervention, supportive services, and case management.
- Assist patients with accessing community resources related to housing, food insecurity, transportation, utilities, employment, insurance coverage, and other social support services.
- Collaborate with medical, dental, behavioral health, and care management teams to develop and implement patient-centered care plans.
- Support patients experiencing chronic illness, behavioral health concerns, substance use disorders, domestic violence, trauma, or other complex challenges.
- Educate patients and families regarding available community resources and healthcare services.
- Facilitate referrals to behavioral health providers, specialty care providers, social service agencies, and community organizations.
- Monitor patient progress and follow up to ensure continuity of care and successful resource connection.
- Assist in identifying, enrolling, and engaging participants for grant-funded programs.
- Provide case management and support services for grant participants.
- Maintain required documentation and data collection for grant reporting and compliance.
- Assist with program outreach, participant recruitment, retention efforts, and community engagement activities.
- Track participant outcomes and support quality improvement initiatives.
- Collaborate with grant managers, program staff, and community partners to meet program objectives and deliverables.
- Participate in grant-related meetings, audits, monitoring activities, and reporting requirements.
- Develop and maintain relationships with community agencies, social service organizations, educational institutions, and other stakeholders.
- Serve as a liaison between patients, healthcare providers, and community resources.
- Participate in health fairs, outreach events, and community education activities as needed.
- Assist with addressing barriers to healthcare access and promoting health equity throughout the service area.
- Support population health initiatives and community needs assessment activities.
- Maintain accurate and timely documentation in the electronic health record (EHR).
- Ensure compliance with FQHC, HRSA, state, federal, grant, and organizational requirements.
- Protect patient confidentiality and adhere to HIPAA regulations.
- Participate in quality improvement and risk management activities.
- Other duties as assigned by management