Clinical Social Worker (Licensed or Associate) Spanish Bilingual

Lyon-Martin Community Health Services • San Francisco, CA

8d • $39 - $49 • Hybrid

About The Position

The Clinical Social Worker (CSW) provides comprehensive case management services to patients of Lyon-Martin. Working closely with a multidisciplinary team, the CSW assesses patient needs, coordinates care, and connects patients to medical, mental health, and social services. They are responsible for providing clinically appropriate Case Management and Crisis Intervention services, including but not limited to: substance use disorder counseling, crisis intervention and de-escalation, safety planning, and appropriate internal/external referrals. The CSW is expected to maintain a high degree of professional competence and the highest possible ethical standards, and to work collaboratively as part of an integrated health care team.

Requirements

• Graduation from an accredited school of social work.
• Licensed in California as an LCSW or ASW.
• Extensive knowledge of Bay Area public benefit resources and networks.
• Excellent de-escalation and non-violent communication skills.
• Experience safety planning for individuals in crisis, particularly those with suicidal ideation.
• Experience mediating using a restorative justice principles and practices; ability to facilitate accountability conversations.
• Strong interpersonal skills, with an emphasis on empathy and patient-centered care.
• Culturally sensitive/humble and able to work with diverse populations.
• Strong proficiency with EHR systems, Microsoft Office applications, specifically Word, Outlook, internet applications, zoom, computer technology, and phone use
• Experience working with lesbian, bisexual, transgender, gender non-conforming, non-binary, and intersex communities, populations with varying disabilities, racial, ethnic and cultural backgrounds and economic statuses, people who do sex work, those experiencing homelessness, people who have challenges with severe mental illness, people who use drugs, those of with a history of incarceration, people of varying ages.
• An interest in and commitment to accessible gender affirming health care, abortion and primary care for marginalized populations.

Nice To Haves

• LCSW
• Bilingual Spanish/English fluency; other bilingual or multilingual fluency
• Experience using Epic
• At least 2 years of experience providing case management in a community clinic or hospital setting.

Responsibilities

• Conduct comprehensive intake assessments, including medical, psychological, and social factors, to identify patient needs and goals, as well as social determinants of health that may impact well-being, such as challenges with stable housing, employment or food access.
• Develop individualized care plans that address the physical, mental, and social well-being of the patient.
• Collaborate with the patient, their family, and their care team to establish goals and interventions tailored to their needs and desires.
• Serve as a liaison between patients, healthcare providers, and external organizations to ensure their care is coordinated and that there is shared consent and understanding of care plans, empowering them to make informed decisions about their care.
• Assist patients with scheduling appointments, arranging transportation (Paratransit, Tokens, Lyft), interpretation access, and navigating the healthcare system, assisting patients in overcoming barriers to care. May accompany clients to appointments.
• Provide and coordinate referrals and assist with the completion of paperwork to ensure access to appropriate wraparound services, such as housing (Coordinated Entry, Our Trans Home, Open House), financial assistance programs (CAAP, GA, guaranteed income programs, SDI, SSDI), food resources (SNAP, Project Open Hand, Meals on Wheels, Lyon-Martin’s Community Fridge), In-Home Support Services, higher-level mental health services, and more.
• Provide immediate triage and intervention for patients presenting with suicidal ideation or mental health crises.
• Conduct risk assessments to determine the level of care required, including the need for emergency psychiatric services, intensive outpatient programs, residential or inpatient treatment.
• Develop safety plans with the patients in crisis, including participating in follow-up care and monitoring. Develop preventative strategies and conduct regular check-ins or provide a warm-hand off to accessible mental health services.
• Maintain open communication with the care team to ensure patient safety and well-being throughout and after the crisis.
• Collaborate with team to ensure access to long-term care and recovery.
• Lead restorative justice and accountability conversations with clients who break Lyon-Martin’s community agreements, focusing on building a shared understanding of motivations behind their behavior and supporting clients in planning for future situations where they may struggle to meet expectations, ensuring appropriate resources and plans are in place.
• Facilitate discussions about why the behavior was unacceptable, harm caused, and work with the client to agree on a commitment to appropriate behavior in the future.
• Communicate consequences clearly if behavior is repeated and follow through on those consequences in collaboration with the care team.
• Maintain accurate, timely documentation of all case management activities, including crisis interventions and accountability processes in the EHR, Epic.
• Complete all visit notes and respond to in-basket messages within 72 hours, same day if urgent.
• Regularly monitor patient progress and update care plans to reflect changes in their condition or situation.
• Meets productivity and quality indicator benchmarks, maintaining caseload of paneled patients seen at a minimum of 3 patients per half day.
• Adhere to all FQHC, federal, state, and city regulations, including HIPAA to ensure patient privacy and confidentiality.
• Participate in weekly Case Management Team Meetings, Collaborative Care Meetings, All Staff Meetings, and any applicable subcommittee meetings to discuss patient care with the integrated multidisciplinary team with the aim of improving patient experience and health outcomes, especially for high-risk or complex cases.
• Engage in professional development to stay informed on best practices in case management, crisis intervention, restorative justice, and patient care.
• Engages with clients who have high no-show rates or utilize emergency care at high rates to support access to care.
• Facilitate group(s) therapy to foster safety, consistency, and connection to community, as needed.
• Accompanies clients to referral or social services appointments as needed.

Benefits

• 100% employer paid Platinum level medical plans for both employees and their minor dependent(s)
• Premium dental
• vision
• life and acupuncture/chiropractic plans
• up to 3% 403b match
• access to pre-tax health, dependent care and commuter benefits
• professional development funds

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level