Part of a community health team that addresses public health issues by conducting point-of-care screening services, providing education through community and clinic services, and coordinating chronic disease management and social services for individuals and families. Provides social support, health system navigation, community resource linkage and behavior change counseling to Medicaid patients in the community, and at times, in the clinic. Actively coordinates with payors, primary care providers and community organizations essential in the physical, social and behavioral care delivery to provide for seamless coordination between physical, behavioral and social supportive services.
We are looking for people who are:
Flexible, Organized, Goal Oriented, Empathetic, Critical Thinkers, Self-Driven, Punctual, Relationship Focused, Personable, Committed, Team Focused, Whole-Person Focused
Essential Job Functions:
- Supports and monitors community-based referrals to pre-identified population; this includes, but is not limited to, concrete resource connection, coordination of appointments and follow-up, and assisting in obtaining needed documentation
- Explores coverage of services to address identified needs through other sources, including services provided under Medical Assistance, insurance-specific plan and other community resources
- Identify, coordinate and assist members in gaining access to needed supportive services and Medical Assistance services, as well as non-Medicaid funded medical, social, housing, educational, and other services and supports
- Utilize technology to conduct specific screeners that identify social barriers to health; coordinate appropriate referral(s) based on assessment
- Leads community outreach efforts; ensure proper patient information is gathered at time of encounter; collect data on program activities
- Work with organizations such as schools, day cares, churches and grocery stores to build our footprint and provide supportive services to community
- Conducts patients outreach as needed for engagement, retention and/or follow-up
- Electronically document activities, patient information and interventions in designated tracking system
- Remain up-to-date on knowledge of community resources appropriate to the needs of members/families
- Utilizes motivational interviewing and psycho-education with appropriate members to mitigate risks for loss of social service benefits, inactive coverage, substance abuse, chronic disease exacerbation and prevention strategies
- Maintains documentation in compliance with state, federal, professional and ethical guidelines
Please note: This job description is not designed to cover a comprehensive list of duties or responsibilities that are required for this position. Duties and responsibilities may change with or without notice.
Essential Job Skills:
- Cultural competency and the ability to provide informed advocacy
- Ability to demonstrate reliability and responsiveness to members, families and team members.
- Ability to demonstrate mutual respect and build a trusting environment with members, families and team members
- Shares and receives information, concerns and feedback in a supportive manner
- Ability to participate towards a common goal, reinforcing individual capabilities
- Seeks to build on strengths
- Ability to assess external factors that impact health and behavior
- Practices shared accountability between members, families, teams and partners
- Ability to show empathy
About The Company:
CityLife Neighborhood Clinics… Improving health block by block… It’s a movement! CityLife is changing how patients think about primary care. A primary care physician has always been the first stop to diagnose & treat illness. Now, primary care is not only where you go when you are sick & want to feel better. It’s where you go when you need help with the health care system & where you go when you are well & want to get healthier. Only you can improve your health, but you do not have to do it alone. At CityLife, we know health is more than just physical, which is why we have a team in place to take care of the whole you, as a person, & not as a condition! The health care system is hard to navigate. At CityLife we have made it our mission to make health care easier by offering urgent care, walk-in care, same-day visits & so much more!
- High school diploma/GED
- Long-time resident of New Jersey (Essex County/Mercer County preferred)
- Knowledge of resources in the community
- At least two years of experience in public health/community health setting
- Bachelor’s degree in social work (BSW)
- Bilingual (English and Spanish speaking)
- Previous experience as an outreach worker or resource connector
- Weight lifted or force exerted: Up to 10 pounds (over 1/3 time), Up to 25 pounds (under 1/3 time)
- Special vision requirements: Close vision (clear vision at 20 inches or less), Ability to adjust focus (ability to adjust the eye to bring an object into sharp focus).
Licensed Clinical Social Worker (Lcsw)
Hospital Information Systems