Job Description

PHMC's Mission is to be the premier regional provider of integrated, community-based healthcare by combining evidence-based clinical practices, outstanding client service, innovative care partnerships, and team-driven excellence, within a healthy fiscal environment.

A Social Worker (SW) is sought to work as a part of the Integrated Health Services team at the PHMC Health Network. The Social Worker will report to the Health Network Social Services Manager and will be an integral part of the health care team, providing services to clients who come to the center for care.

The SW will meet with each new client seen by the providers to thoroughly screen and assess the client’s Social Determinants of Health and to connect the client to appropriate social service supports and resources. The SW will provide essential information regarding community resources to clients, their families, and the health center team. They will also work closely with the health center team to coordinate client care and to improve client health outcomes. The MSW will also assist clients and their families in connecting to and navigating health insurance coverage and other public benefits. Administrative duties include assessment & planning documentation, referral tracking, and service coordination and follow-up.
Social services include but are not limited to mental health and/or substance use treatment; advance directives, transportation assistance; food resources; financial counseling; education and employment assistance; and legal aid referrals. Must be fluent in Spanish.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Assess client needs and barriers to accessing health, behavioral health, and social support services.
• Assess client needs and provide referrals to appropriate social services agencies (e.g., transportation, housing, utility assistance programs, legal aid, employment assistance, etc.) and demonstrate up-to-date knowledge of community resources, especially those benefiting families and persons with low or lost income.
• Facilitate communication and positive relationship building between clients and medical providers.
• Incorporate strength-based assessment and brief problem-solving interventions, as appropriate, aimed at modifying negative thinking and promoting self-efficacy.
• Assist clients in applying for and navigating health insurance coverage, public benefits, and exploration of entitlement programs such as social security and veteran benefits.
• Interface with clients and managed care companies to facilitate Primary Care Provider (PCP) switches.
• Actively participate as a member of the interdisciplinary health care team (IDT).
• Collaborate with the Center of Excellence (COE) Community-Based Care Management team and Peer Recovery Program to both address psychosocial health issues and to coordinate care among providers and outside specialists.
• Foster and maintain partnerships with other social service agencies.
• Participate in training to become a Certified Application Counselor for the Health Insurance Marketplace and assist consumers with application and enrollment.
• Participate in Social Services Team supervision, meetings, and information & skill sharing processes.
• Document all services daily in the appropriate electronic health records system and other social service reporting formats.

SKILLS:
• Thorough knowledge of community resources, especially those that support families and individuals with low incomes, and individuals experiencing homelessness
• Knowledge of Pennsylvania public benefits and DHS system (Medicaid, SNAP, TANF, etc.)
• Knowledge of DSM 5 behavioral health conditions and working knowledge of chronic diseases
• Strong commitment to supporting and advocating for the homeless population of cities
• Ability to exercise strong clinical judgment, independent analysis, and critical thinking skills
• Excellent time management skills and attention to detail to attend to caseload expectations and ensure timely documentation
• Excellent ability to work and maintain flexibility in a fast-paced medical environment
• Strong ability to prioritize work demands, including casework and administrative tasks
• Strong interpersonal, organizational, and oral/written communication skills
• Knowledge of and sensitivity to the impact of intergenerational poverty
• Developed multicultural competency and desire to collaboratively work with vulnerable clients from marginalized populations
• Proficiency in computer skills, including Microsoft Word, Excel, and Outlook, and willingness to learn new technology such as electronic health record systems
• Ability to represent the agency and facilitate relationships with the community

EXPERIENCE Required:
• Experience with crisis intervention and harm reduction
• Experience working with those experiencing homelessness
• Experience working with families and individuals with low or no income
• Experience working as a member of an interdisciplinary team
• Experience with crisis intervention and harm reduction is a plus
• Minimum of 3 years’ experience, working in case management and social services
• Comfort with evidence-based interventions such mas otivational interviewing
• Comfort working with diverse populations (i.e., race, ethnicity, diagnoses, age ranges)

EDUCATION REQUIREMENT: Master’s Degree in Social Work or related.

PHMC is an Equal Opportunity and E-Verify Employer.