Social Worker Care Advocate, Full Time Days

Cape Fear Valley Health

7d•Onsite

About The Position

The Care Advocate serves as the trusted point of contact for pregnant and postpartum patients from enrollment through 12 months postpartum. The role combines empathetic engagement, structured brief assessment/intervention, care planning with shared decision-making, motivational interviewing techniques, closed-loop referrals, and consistent communication with OB, pediatrics, primary care, behavioral health, and community partners. The Care Advocate documents all contacts, follows site safety protocols, and contributes to quality improvement and evaluation.

Requirements

Masters degree in social work required
Licensed Clinical Social Worker in North Carolina required
2 years in care coordination/case management or patient navigation required
2 years of experience in behavioral health management required
1 year of experience conducting mental health/SUD risk assessments, brief interventions and referrals required
Proficiency in reading, writing and speaking the English language
Knowledge of community resources and patient advocacy; experience with diverse populations and equity-focused, trauma-informed care.
Proficiency with technology-enabled communication (texting platforms, telehealth) and accurate documentation
Excellent interpersonal communication and negotiation skills
Ability to communicate effectively and work with people of all social, economic and cultural backgrounds
Proven written, telephonic and electronic communication skills
Assertive and persuasive interactions with customers, peers, management and core staff served
Strong organizational and time management skills
Flexible, open-minded and adaptable to change

Nice To Haves

1 year of experience in obstetrics or maternal health preferred
Bilingual (English/Spanish) preferred

Responsibilities

Review automated screening results and relevant EHR information daily.
Conduct phone or video assessments for positive screens (mental health, substance use, IPV, SDoH, high-risk conditions).
Deliver brief interventions (SBIRT principles), education, and collaborative care plans using motivational interviewing and shared decision-making.
Triage and manage risks; escalate medical concerns to nursing/APRN partners and behavioral health emergencies per SOPs (suicide, overdose, psychiatric crisis, IPV danger).
Complete warm handoffs; schedule with internal/external providers; ensure information exchange consistent with privacy laws and consents.
Confirm engagement with referrals; troubleshoot barriers (transport, childcare, cost, coverage, language, etc.); re-engage as needed.
Document assessments, plans, and follow-ups in the program platform and per site EHR standards (progress notes, messages).
Communicate promptly with clinical teams about risks, plans, and updates; use closed-loop processes.
Maintain accurate, timely logs and dashboards for fidelity and performance monitoring.
Contribute to building and updating the site resource library; tailor resource lists to geography and patient preferences.
Collaborate with the Patient Engagement Lead and community partners to strengthen pathways and reduce handoff failures.
Other duties as assigned