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 resourcesforspecialtycommunityresourceprograms;providesopportunitiesforpatientstolearnskillstofostergreater 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.DemonstratesasincerededicationandloyaltytothephilosophyandmissionofNeighborhoodHealth.DUTIES/RESPONSIBILITIES:(EssentialFunctions:Dutiesandresponsibilitiesnotedwithbulletsareconsideredtobe the essential functions of the job)Meets individually with patients to provide a variety of services including support with obtainingfinancialassistanceformedicalbills,coordinatingtransportationtospecialtycareappointments,and assisting patients with scheduling specialty appointments, interpretation/translation, while providing opportunities for patients to develop and strengthen these skills and increase self-sufficiency.Supportsintegratedprimarycarebehavioralhealthinitiativebyprovidingtargetedcasemanagementunderthe direction of behavioral health and medical providers to reinforce specific behavior modification plans through telephone encountersaswellasfacilitatingreferralsofpatientstospecialty medical andbehavioralhealthserviceswhenneedsare identified.Providestargetedcasemanagementforpatientswithchronicillnessexperiencingbarrierstoachievinghealth and wellness goals.Providesadministrativesupportforbehavioraltherapistsincludingscanningofpatientdocuments,obtaining treatment records and assisting patients in obtaining behavioral health appointments as needed.Ensuresuniversalhealthscreeningprocessiscompletedatassignedclinicsitesandassistinprocess improvement plans as need.RespondstotheneedsofpatientsdemonstratingriskysubstanceusebehaviorsusingSBIRTmodel.Servesasaresourcetoclinicalteamandprovidersinthetreatmentofsubstanceusedisorders.Maintainsanupdateddatabaseofcommunityresources(e.g.,financialassistance,food,clothing,employment, shelter/housing, etc.) and periodically updates clinical team members on availability of resources.Collaborateswithmedicalproviders, nursingstaffandreferralcoordinators inassistingpatientswithcomplex medicalneedstoobtainneededservices,includingtranslationofpatienteducationmaterialsandinstructions for hospital procedures.Establishesandmaintainsstrongworkingrelationshipswithcommunitypartnerstofacilitateaccesstoresources such as food banks, clothing programs, financial and charity programs.Managesthedistributionofannualspecialtyservicessuchascoatdrives,turkeydistributionandotherservices as available.Documentsallservicesintheelectronicmedicalrecord,inaccordancewithorganization'sstandards.Respondstoallcommunication,bothinternalandexternal,inatimelymanner.Providescoverageforothercaseloadswhenneeded.Maintainsrecordsaccordingtoestablishedguidelines.AttendsandparticipatesinDepartmentandorganizationmeetingsbysharingknowledge,experiences,and information regarding team members, clients, work practices, etc.Mayparticipateinagencyworkgroupsand/orteams.Attendsandparticipatesinon-goingtraining,learningandgrowthopportunities.Maintainspolicymanualsincorporatingchangeswhenreceived.Attendsallstaffmeetings.Attendsrelevantcontinuingeducationeventsandtrainingasidentifiedandapprovedbysupervisor.OTHERDUTIES:PrepareandmaintainspecialinternalandexternalreportsasrequestedbySupervisorand/orDepartmentHead.Assistwithdeveloping,coordinatingandrecommendingchangesfortheimprovementofworkflowinthe program or section area.Maybeassignedtovariousprojectleadrolestoadvancethedevelopmentofthedepartmentandsupportad hoc needs.Abletoworkunderminimalsupervision.Employeewillbeaskedtoperformadditionaldutiesandtakeonotherresponsibilitiesasdictatedbyeventsand circumstances.QUALIFICATION/EDUCATIONand/orEXPERIENCEREQUIREMENTS:AssociateDegreeand/orhighereducationpreferred.2-3yearsdirectexperienceworkinginacommunity-basedsettingprovidingcasemanagement or other enabling services.Strong skills in building patient rapport, timemanagement, organization and attention to detail.ExperienceinaPatientCenteredMedicalHomesettingisstrongly preferred.Excellentinterpersonalcommunicationskillsandtheabilitytoworkeffectivelywithadiverseworkforceand client base.ProficientwithMicrosoftWindowsandMicrosoftOffice,includingWordandExcel.Self-disciplined,mature,independent,outstandingoralandwrittencommunicationskills.Mustbeabletomaintainconfidentialitywithallaspectsofinformationinaccordancewithpractice,Stateand Federal regulations.Mustbecomfortableworkingwithculturallydiversepopulations.Demonstratesuperiorcriticalthinkingskills,soundjudgment,anddecision-makingandproblem-solvingskills.Knowledgeoflocalhealthcareenvironmentandbasicterminology.Fluency in Spanish required.