Social Worker III SDOH

JOB SUMMARY:

The Social Worker, SDOH Program & Equity conducts direct service coordination for agency service recipients to ensure that needed support services and community resources are provided and accessed, leading to an improved quality of life, and provides supervision and coordination with other Case Managers/Social Workers in the department or program area, while ensuring that services provided are in alignment with the Social Determinants of Health through a trauma informed care lens as defined by the agency. This position works a collaboratively with healthcare systems and community-based entities to provide needed services with the objective to improve long-term health outcomes.

ORGANIZATIONAL RELATIONSHIPS:

1. Reports to:

Manager, SDOH Program & Health Equity, or other designee

2. Directs:

N/A

3. Other:

Works cooperatively with all staff to accomplish the mission, goals, objectives and performance measures of the program and agency

ESSENTIAL PERFORMANCE REQUIREMENTS AND FUNCTIONS:

Required Competencies/Skills:

1. Healthcare and Human Services Environments: Ability to explain issues and advancements in the healthcare and human services industries.

2. Achievement Orientation: A concern for surpassing a standard of excellence. The standard may be one's own past performance; an objective measure; outperforming others; challenging goals, or something that has not been done previously.

3. Community Orientation: Ability to align one's own and the organization's priorities and assess and address community needs in an evidence-based and holistic manner, one that addresses the social determinants of health through a trauma-informed lens.

4. Professionalism and Ethics: The demonstration of ethics and sound professional practices, as well as stimulation social accountability and community stewardship. The desire to act in a way that is consistent with one's values and what one says is important.

5. Interpersonal Understanding: Ability to understand other people as well as to accurately hear and understand the unspoken or partly expressed thoughts, feelings, and concerns of others. It measures increasing complexity and depth of understanding of others and includes cross-cultural sensitivity through a trauma-informed care lens.

Essential Functions:

1. Ensures that clients have access, as needed, to all five pillars of the social determinants of health with a trauma informed lens through Agency services and/or community partners.

2. Works with patients to provide care, resources, warm referrals to internal and/or external linkages, follow up, and reporting into patient records. Provide essential services to individuals and families in crisis. Performs home visits with clients as needed.

3. Work with patients of various acuity levels who have health challenges affected by or tied to social determinants of health. In coordination with Health Care systems create a referral process, client engagement prior to discharge process and longer-term intervention processes to successfully assess and address any client Social Determinants of Health Barriers.

4. Conduct an initial eligibility screening with potential service recipients for initiation of services.

5. Conduct an assessment of each case within thirty (30) working days, or as mandated by contractual requirements after the initial screening, or as may be required by applicable contract requirements, as the basis for service planning, delivery and case coordination with the active participation of the service recipient and/or family members, as appropriate.

6. Develop an individualized service plan for each client within ten (1) working days of completing the assessment, or as mandated by specific contract or program curriculum requirements involving the service recipient and/or family members, as appropriate.

7. Re-evaluate the service recipient’s status a minimum of every thirty (30) days, or as mandated by contractual requirements, and respond to the changing needs and circumstances of persons receiving services. Update service plan as needed, with all follow up visits.

8. Maintain service recipient records and database for monthly, quarterly and annual statistical reports.

9. Directly provide, contract, refer, or otherwise arrange for service recipient to receive needed services, such as counseling, transportation, homemaker, medical, group support services, or other services and community resources as needed.

10. Provide case consultation to other direct service providers as appropriate. Participates in workgroups to plan, assess, and adapt practices and strategies that promote the SDOH Program & Health Equity.

11. Maintain service recipient and family member confidentiality in accordance with agency standards and coordinates the provision of social services to participants, families, and significant others to enable them to achieve maximum benefits from services.

12. Effectively utilize Software to enter and track deliverables.

13. Attend general staff meetings, peer consultations, multidisciplinary case conferences and trainings as required.

14. Maintain good relationships with stakeholders (including current and potential clients, community and co-workers), focusing on providing excellent and culturally sensitive customer service and presenting a positive image of the agency in all community and stakeholder interactions. Participates in research and evaluation opportunities with partners.

15. Maintain a working environment which encourages mutual respect, promotes respectful and congenial relationships between employees and is free from all forms of harassment.

16. Perform other duties as assigned, including presentations to community groups and organizations, in accordance with the agency’s “team” philosophy.

QUALIFICATIONS:

To perform this job satisfactorily, an individual must be able to perform each essential performance requirement satisfactorily. The requirements listed below are representative of the training, experience, knowledge, and skills required for this job. Reasonable accommodation may be made to enable an individual with disabilities to perform the essential functions listed above.

Education/Training/Experience:

1. Master’s degree in social work or a related behavioral science area of study.

2. Previous experience working with community based entities and/or healthcare systems to provide needed services with the objective to improve long-term health outcomes.

3. At least two (2) years experience with successful direct case management and coordination and supervision of other case managers and/or social service professionals.

4. Understands cultural differences and is sensitive to the implications of culture for service delivery.

5. Demonstrated knowledge of basic community resources and of making referrals and providing follow-up consultation.

6. Fluent in English and Spanish (read, write, and speak) desirable.

7. Staff will be required to submit proof of their vaccination status or may request to be exempt from vaccination due to a religious and/or medical accommodation.

8. Certificate or license, as applicable, by the appropriate State agency as a qualified practitioner.

9. State of Texas vehicle operator’s license and proof of liability insurance.