Position Summary:
Under the direct supervision of the Social Services Manager and Social Services Supervisor, the Social Worker will provide SYHealth patients with support, advocacy, development and monitoring of caseload to ensure the health, safety, and well-being of vulnerable and high-risk population.

Essential Functions of the Job:

• Responsible for proactive case management with the objective of improving health outcome and providing social service support to all SYHealth patients.
• Provide patients and families with face to face psychosocial assessments, interventions, support, advocacy, and case management.
• Perform in-depth screening for internal and external community programs for the purpose of educating, navigating and connecting patients with needed services.
• Obtain written authorization from patients and create patient profiles on the Community Information Exchange (CIE) system.
• Use active listening and conversational intent in all interactions to provide high-quality confidential connections to resources and services to all SYHealth patients.
• Using needs assessment, identify programs and resources to assist patients based on the social determinants of health utilizing the PRAPARE Tool.
• Actively listen to clients to develop a strategy that identifies solutions to barriers to access.
• Develop and implement case management plan in collaboration with the patient, caregiver, physician and/or other appropriate healthcare professionals and patients support network to address their needs and goals.
• Maintains ongoing patient case load for ongoing continuity of care.
• Assesses for barriers to care, provide care coordination and assistance to patients to address concerns.
• Maintains a working knowledge of facility service areas including transportation, community characteristics, and geography.
• Accurately document all patient interactions and unmet needs into NextGen to assist in the identification of gaps in services that can be addressed organizationally.
• Comply with Community Information Exchange regulations and complete all CIE trainings.
• Keep all activities in line with the core values and contribute to the positive culture of SYHealth.
• Maintain accurate records of all activities performed and submit pertinent reports by due dates.
• Represent SYHealth in an effective and professional manner and maintains positive working relationship with the general public, clients, patients, co-workers and other agencies.

Additional Duties and Responsibilities:
This job description is in no way meant to describe exactly and only what the position entails. It is a guideline to provide a frame of reference of the job requirements. Performs additional duties as assigned or requested.

Job Requirements: Education Required (Minimum level of education):
Bachelor’s Degree, preferably in a Social Sciences or related field.
Social Work, Psychology, Gerontology, and/or Sociology preferred.

Certifications/Licenses Required:
CA driver’s license with appropriate insurance coverage. Properly insured vehicle.
CPR/First Aid certification preferred.

Experience Required (Minimum level of experience):
Experience as Clinical Social Worker with at least 6 months in a clinical healthcare setting and administration experience.

Verbal and Written Skills Required to perform the Job:
Bilingual (English and Spanish). Excellent written and verbal communication skills.

Technical Knowledge and Skills Required Performing the Job:

• Skills in counseling theory and techniques.
• Knowledge of community resources and their use to meet the needs of the families.
• Have organization and project management skills.
• Ability to establish and maintain good interpersonal relationships.
• Ability to work independently and meet deadlines.

Equipment Used:
Office equipment, including but not limited to: computers, phones, copy machines, fax machines.

Working Conditions and Physical Requirements:
Prolonged periods of sitting and standing. Frequent walking. Driving within the city. Lifting of up to 15 pounds. Ability to remain calm and objectively evaluate problems. May be required to work outside normal working hours. The ability to work remotely.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.


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