POSITION SUMMARY:

Under the direction of the Medical Care Coordination Team Supervisor, the Patient Support Services (PSS) Social Worker will provide the appropriate level of coordinated health care services for patients of APLA Health & Wellness. Staff will provide and promote health and wellness through the PSS services, and education to people living with HIV/AIDS. As part of the MCC/PSS team, provides assessment, integrated care planning, and progress monitoring for patients enrolled in MCC.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Complete bio-psychosocial assessments; develop a treatment plan, and coordinate appropriate referrals that address the collaborative clinical goals of clinician and patient and document in treatment care plans.
• Identify high–risk patients, conduct initial screening & risk assessments, conduct intake & assessment, develop a patient centered risk reduction treatment plan with patients; implement documentation according to DHSP requirements.
• Provide behavioral health referrals, advocacy, and service information to patients.
• Evaluate patients for eligibility for PSS enrollment. Determine patient acuity and assist in the development of an integrated care plan to address assessed needs.
• Conduct brief interventions for PSS-enrolled patients focusing on improving patient’s status as it relates to issues of addiction, mental health distress, risk reduction, and disclosure interventions.
• Use the Transtheoretical model of behavior change to support improved health outcomes for PSS patients including treatment engagement and retention, medication adherence, risk reduction, and health provider communication.
• Maintain ongoing contact with PSS patients and monitor progress related to goals set in the individual care plan.
• Coordinate and communicate among members of the PSS patient’s care team including medical providers, mental health/addiction providers, allied health, community resources, and other PSS team members. Participate in interdisciplinary case conferences for assigned PSS patients.
• Conduct PSS services in accordance with Medical Care Coordination guidelines published by the LA County Department of Public Health, Division of HIV and STD Programs as existing or amended.
• Screen, assess, and plan appropriate interventions to minimize patient risk of acquiring or transmitting sexually transmitted infections.
• Document services in eClinicalWorks, and/or other charting and data collection systems as appropriate. Documentation will be performed in a timely and accurate fashion in accordance with program policies and professional standards of care.
• Adhere to all applicable professional, legal, and ethical standards of behavioral health practice in the provision of services, including but not limited to: mandated reporting, provision of effective services, case documentation, patient confidentiality/HIPAA regulations, ensuring patient safety, and maintaining professional boundaries.
• Attend trainings and case conference meetings as required.
• Prepare monthly reports and statistics as requested.

OTHER DUTIES MAY BE ASSIGNED TO MEET BUSINESS NEEDS.

REQUIREMENTS:

Training and Experience:

A Master’s Degree in Social Work, or Counseling. Knowledge of behavioral health issues and effective treatment modalities; HIV behavioral health issues; ability to perform differential diagnosis using the DSM-V; various theoretical orientations; treatment modalities; clinical techniques and interventions; treatment planning; biopsychosocial assessment; crisis intervention and reporting obligations; HIV risk reduction counseling; HIV Prevention strategies; reporting obligations and available community services and resources; motivational interviewing, theories of change and harm reduction methods.

Ability to:

Communicate effectively orally and in writing; organize work in an effective manner; work in a collaborative, interdisciplinary, fast paced environment; work effectively independently and as part of a team; communicate and relate to a variety of personalities, ethnicities, and sexual orientations; complete documentation in a comprehensive and timely fashion in accordance with APLA H&W policies.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS:

This is primarily an office position that requires only occasional bending, reaching, stooping, lifting and moving of office materials weighing 25 pounds or less. The position requires daily use of a personal computer and requires entering, viewing, and revising text and graphics on the computer terminal and on paper.

SPECIAL REQUIREMENTS:

Must possess a valid California driver’s license; proof of auto liability insurance; and have the use of a personal vehicle for work related purposes. COVID vaccination required or medical/religious exemption.

Equal Opportunity Employer: minority/female/transgender/disability/veteran.