Transitional Housing Clinical Outreach Social Worker

OHSU•Portland, OR

61d•Hybrid

About The Position

The Clinical Outreach Social Worker (COSW) uses advanced clinical and/or healthcare operational subject matter expertise combined with systems and workflow knowledge to manage and assist in compassionate interventions to patients with complex psychosocial needs who discharge from OHSU Emergency Department and hospital. The COSW prioritizes clients with limited connections to outpatient services and frequent ED encounters. This population is growing in numbers, cost and complexity. This work requires unique skill set, flexibility and vast network of community partners to be able to effectively offer care. Job responsibilities include identifying enrollees, conducting needs assessments, identifying appropriate resources, and facilitating service engagement via face-to-face outreach and phone contact. Assessments and services are offered in the ED, hospital, on the streets and in homeless camps, in patient homes, outpatient clinics, and other community settings. The COSW coordinates treatment efforts with other OHSU departments, partners, community partners and affiliates to advocate for client needs. Interventions aim to reduce unnecessary hospital and ED visits by improving access to medical care, substance use disorder treatment, mental health services and housing. While assisting clients in accessing services, the COSW identifies client strengths, models problem-solving skills, encourages mutual participation, and enhances self-advocacy abilities. The COSW participates in data collection for program evaluation purposes and partners with other team members to ensure effective implementation of services. The COSW's values and care delivery are consistent with the NASW code of ethics. Specialty Addendum for this Transitional Housing COSW position: The TH COSW will provide specific direct service supports to patients in both the inpatient units and in the community to facilitate patients getting the appropriate level of care and resources. This Transitional Housing Clinical Outreach Social Worker will be supporting the Transitional care teams and TC motels, and will including hospital in-reach and in person community based outreach supports. This position will take lead on inpatient social work discharge planning and outreach care coordination for patients identified as participants in one of the OHSU Care Management Transitional care service lines (motels, RCP, AFH, ICF, etc). This position is a flexible work position, which allows some remote work. Remote work at OHSU is a work arrangement under which an employee performs the duties and responsibilities of their position, and other authorized activities, from a non-OHSU location as part of their approved, regular work schedule. The Social Worker generally is expected to be in person at least half of their work time, depending on the expectations of their specific position. The social worker should have a private space at home, dedicated to work, and no Protected Health Information should be printed. Social Workers are expected to see patients in person, when at all possible, which may require coming to the hospital at short notice on a remote day.

Requirements

Master's in Social Work
Current Oregon LCSW license required if Social Worker is hired.
BLS required at time of hire, issued by the American Heart Association (AHA) or Military Training Network branch of AHA
3+ years work experience in healthcare disciplines, including but not limited to care coordination, case management, community mental health, chronic illness, patient education and complex social issues; other relevant experience, includes working with an adult under-served population and work in the Portland area safety-net.
Must have familiarity with common outpatient medications and general medical knowledge.
Valid OR/WA driver's license with an acceptable driving history and access to a car on a daily basis for home visits.

Nice To Haves

LCSW preferred.
5+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings.
Experience working within the Portland social service community and extensive knowledge of community resources.
Experience conducting home visits and street outreach.
Familiar with street safety assessment and crisis interventions and response.
Post Graduate training and certification applicable to the job

Responsibilities

Care planning
Coordination of care
Strategic Partner Facilitation
Clinical services
Case management
Clinical Practice
Interface with insurance companies
Social Determinants of Health (SDOH)

Benefits

Healthcare Options - Covered 100% for full-time employees and 88% for dependents, and $25K of term life insurance provided at no cost to the employee
Two separate above market pension plans to choose from
Vacation- up to 200 hours per year depending on length of service
Sick Leave- up to 96 hours per year
8 paid holidays per year
Substantial Tri-met and C-Tran discounts
Additional Programs including: Tuition Reimbursement and Employee Assistance Program (EAP)

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