Engagement Social Worker (Social Worker Level II), IPA Project Operations *Temporary/Grant Funded*

About NYC Health + Hospitals

Empower Every New Yorker Without Exception to Live the Healthiest Life Possible

NYC Health + Hospitals is the largest public health care system in the United States. We provide essential outpatient, inpatient and home-based services to more than one million New Yorkers every year across the city’s five boroughs.

Our large health system consists of ambulatory centers, acute care centers, post-acute care / long-term care, rehabilitation programs, Home Care, and Correctional Health Services.

Our diverse workforce is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

The Engagement Social Worker will work under the direction of the facility-based Program Lead as a member of the Special Populations Care Management Program at NYC H+H.

The Engagement Social Worker is an integral member of an interdisciplinary team within the medical emergency room (NYC Health + Hospitals Acute facilities) and community to provide in-reach and outreach services that will bridge patients to longitudinal healthcare services and care management.

The Engagement Social Worker will maintain a caseload of patients and interface with the healthcare and social services team members within and beyond the emergency room to identify medically appropriate and cost-effective care.

The Engagement Social Worker will set an example of approaching care management in a holistic capacity that addresses gaps in care and supports patients to be more self-directed and feel empowered to engage in long-term healthcare resources.

The Engagement Social Worker will be responsible for the following :

• Screen charts for historical and clinical information, identification of existing community-based linkages, and identification of care coordination opportunities.
• Interpret clinical information based on case data, histories, statistics, etc., to prepare and submit comprehensive reports of case findings, including chronologies of medical data and social factors necessary to support recommended courses of action.
• Screen and assess for the treatment of serious mental illness (SMI) and substance use disorder (SUD) diagnosis.
• Complete psychosocial evaluations and referrals for time-sensitive clinically appropriate interventions (such as but not limited to) referrals to higher levels of care during the ED visit or while completing post-ED outreach.
• Provide ongoing support and psychotherapeutic counseling to patients, families, and significant others, and concrete services at a frequency determined by the respective assigned area.
• Coordinate with the Emergency Department clinical treatment team and Engagement Navigator to assess the patient's presenting symptoms & social context that resulted in an ED visit.
• Collaborate with the Engagement Navigator to engage the identified patient and build rapport, assess their level of engagement with current supports, and discuss clinical referrals such as primary care, behavioral health, medical specialty, and longitudinal care models and social services referrals for care management and housing supports.
• Confirm the best method for follow-up contact (cell phone number, emergency contact, and field-based location for outreach), and reinforce the discharge plan outlined by the clinical treatment team.
• Act as an intermediary between patients and providers for discharge planning by scheduling follow-up appointments, assessing the patient's transportation needs, planning to obtain medication post-discharge, and identifying gaps in care.
• Provide complex care management services with a harm reduction and trauma-informed lens prior to linking patients to alternative long-term care model programs within and outside of the H+H system when appropriate.
• Maintain a caseload of ED E+N patients with complex care needs post-ED discharge. The Engagement Social Worker will help address gaps in care post-discharge by scheduling appointments, providing reminders before the appointment, and supporting the patient with linkage for longitudinal care management.
• Conduct fieldwork outreaches within the community to bolster patient engagement with longitudinal healthcare resources.
• Complete outreach activities as required for E+N patients not actively engaged in treatment, such as diligent search activities.
• Complete required documentation in a timely fashion to reflect patient engagement outreaches, provider collaterals, and case conferences : complete preliminary assessments and treatment goals with objectives as outlined in accordance with programmatic requirements.
• Complete comprehensive post-discharge chart reviews to assess the patient's engagement in longitudinal healthcare resources and support the patient in addressing barriers to accessing hospital- and community-based resources.
• Participate in Performance Improvement Projects and Continuing Quality Improvement projects.
• Compliance with all department, corporate, and hospital regulations, policies, and procedures, conformity to established dress guidelines, time and leave requirements as an essential worker, and need to wear an identification badge while on duty.
• Incorporate universal screening of patients to identify if they are a victim of abuse. Follow hospital policies on interventions regarding child abuse, intimate partner violence, elder abuse, sexual assault, and human trafficking, as well as New York State protocols for mandated reporting of suspected child abuse or maltreatment.
• Maintain professional working relationships with other providers to bolster communication across settings.
• Participation in regular supervision and ad-hoc supervision / escalation as necessary to seek guidance from appropriate personnel.
• Perform work-related duties with the understanding that as a hospital employee, one is categorized as an essential worker, which includes coming to assignment under a variety of circumstances such as inclement weather, pandemic, and other extreme circumstances.
• Flexibility to work nontraditional tours at a hospital ED setting
• Perform other duties as required as a part of a multidisciplinary team.

Minimum Qualifications

For Assignment to Level II

1. Valid license as an LMSW issued by the NYSED; or

2. Valid license as an LCSW issued by the NYSED.

Department Preferences

• A valid Licensed Master of Social Work (LMSW) issued by the New York State Education Department and two years of experience utilizing one or a combination of case management (care coordination), casework, group work, and community organization methodologies.
• Prior experience assisting individuals with complex care needs such as individuals experiencing homelessness, criminal legal involvement, serious and persistent mental health diagnosis, substance use dependence and recovery, and intellectual or developmental disabilities.
• Prior experience with managed care, population health management, care management, Medicaid / Medicare populations and policies, health information technology, and provider network support is preferred.
• Prior experience working with PSYCKES, MAPP, EMEDNY, HARP, and HCS is preferred; Redcap or other database development experience is a plus.
• Strong Microsoft Office suite skills (Word, PowerPoint, Excel, Outlook)
• Ability and willingness to conduct field visits (including street and shelters) and outreach activities within the assigned borough(s) of NYC.
• Ability to work nontraditional tours, please specify any exclusions for your schedule in your cover letter.
• Familiarity with harm reduction principles across settings (medical, substance use) and complex care principles (person-centered, equitable, cross-sector, team-based, data-driven).
• Familiarity with supervision, fostering a work culture that is conducive to professional growth, collaboration, and accountability.
• Excellent communication and documentation skills, including the ability to tailor communication style appropriately for various stakeholders
• Excellent organization and attention to detail.
• Solution-focused and resourceful.
• Training in trauma-informed and harm reduction modalities, motivational interviewing, Wellness Recovery Action Plan, Moral Reconation Therapy, Cognitive Behavioral Therapy, and Stages of Change.
• Knowledge of community-based resources within the New York City Metro area.

How To Apply

If you wish to apply for this position, please apply online by clicking the "Apply Now" button.

NYC Health and Hospitals offers a competitive benefits package that includes :

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs
30+ days ago