ACCOUNTABILITIES All duties listed below are essential unless noted otherwise 1. Conducts psychosocial assessments with clients and/or significant others to determine and evaluate the following as appropriate: Support system and family relationships/dynamics Emotional/psychological/cognitive status Substance use/abuse status and history Communication/language barriers Living situation/household composition Education and vocational status Financial stress to the client and family Need for community resources Social and emotional factors negatively impacting access to and compliance with treatment, recovery from illness, economic self-sufficiency, behavioral health status and personal safety Religious and cultural attitudes/beliefs related to physical/psycho/social well-being and adjustment as appropriate Personal safety and presence/risk of domestic violence. Other variables/factors pertinent to the client situation. Social and emotional factors negatively impacting access to medical treatment, recovery from illness, economic self-sufficiency, behavioral health, and personal safety goals. 2. Conducts proactive patient engagement to patients who screen positive for social determinants of health and connect clients to available community resources. 3. Maintains knowledge of age specific community resources for all geographic areas of service and makes referrals to appropriate agencies to meet identified needs, both short and long term. 4. Works cooperatively with multidisciplinary team, other medical providers, clinicians and case managers, involved community partners as needed to address and resolve client needs. 5. Participates in case conferences as appropriate to identify social problems, their severity and their impact on patient’s health as well as the patient and caregiver’s strengths and weaknesses and their ability to handle stressors and discussing alternate methods of resolving situation. 6. Provides counseling and social psychotherapy to clients and significant others in relation to their medical, behavioral, vocational, and social needs. Facilitates referrals for ongoing counseling/therapy as needed. Documents goal-oriented objectives and results achieved from treatment in a clear and conscious manner. 7. Coordinates financial assistance referrals and refers clients/families for financial and employment coaching. 8. Ensures accuracy of clinical documentation. - Participates in comprehensive chart review as needed. - Ensures documentation of assessments, re-visits, follow-up interventions, and resource connection tracking is accurate and timely. 9. Demonstrates the ability to prioritize complex caseload to effectively meet client and staff needs and maintain productivity expectations. 10. Maintains confidentiality of all agency and patient records. 11. Promotes and maintains customer service focused care consistent with system values. 12. Performs other job related duties as assigned.
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Job Type
Full-time
Career Level
Mid Level