Community Outreach Social Worker

Community Outreach Social Worker

The Community Outreach Social Worker is a member of the Project Street Beat (PSB) interdisciplinary team and provides comprehensive case management, psychosocial support, behavioral health screening, crisis assessment, care coordination, and advocacy to individuals experiencing barriers to health care. The Social Worker engages participants in community, mobile health, and clinical settings and collaborates with internal and external partners to improve health outcomes, reduce health disparities, and increase access to equitable, person-centered care.

This position serves populations disproportionately impacted by HIV, sexually transmitted infections, hepatitis C, substance use, behavioral health concerns, housing instability, poverty, and other health inequities. The Social Worker supports participants through outreach, assessment, navigation, brief supportive interventions, referrals, linkage to care, and follow-up.

The Social Worker also provides virtual behavioral health consultation and support across Planned Parenthood of Greater New York (PPGNY) health centers and programs, as needed, while supporting integrated care initiatives and improving participant access to services. Services are provided within the scope of licensure, organizational policy, program requirements, and applicable regulatory standards.

Clinical Assessment, Case Management & Care Coordination — 35%

• Conduct comprehensive psychosocial assessments to identify participant strengths, needs, goals, and barriers to care.
• Assess social determinants of health, including housing, food insecurity, transportation, insurance, employment, behavioral health, safety, legal needs, and other psychosocial concerns.
• Develop individualized care plans in collaboration with participants and the interdisciplinary care team.
• Maintain an assigned caseload and provide ongoing case management, advocacy, care coordination, and follow-up.
• Monitor participant progress and revise care plans as appropriate.
• Coordinate services across internal departments and external community providers to ensure continuity of care.
• Collaborate with medical providers, navigators, outreach staff, behavioral health professionals, and community partners to support integrated care planning.
• Support referrals and care coordination related to HIV prevention and treatment, PrEP and PEP, sexually transmitted infections, hepatitis C, sexual and reproductive health care, Gender-Affirming Hormone Therapy (GAHT), primary care, preventive health services, and supportive services.
• Maintain participant engagement and retention throughout the continuum of care.
• Support multidisciplinary care planning for participants with complex medical, behavioral health, and social needs.

Behavioral Health Support & Crisis Intervention — 20%

• Conduct behavioral health screenings and psychosocial assessments using approved screening tools and program workflows.
• Assess participants for depression, anxiety, trauma, substance use disorders, suicide risk, intimate partner violence, safety concerns, and other behavioral health needs.
• Provide brief supportive interventions, psychosocial support, crisis assessment, safety planning, and care coordination within scope of licensure and program requirements.
• Provide crisis intervention and emotional support when appropriate.
• Develop safety plans in collaboration with participants and care team members when indicated.
• Facilitate warm handoffs and referrals to behavioral health providers, substance use treatment programs, crisis services, and other supportive services.
• Provide virtual behavioral health consultation and support to participants and staff across PPGNY, as appropriate and within role expectations.
• Participa…