Community Outreach Social Worker
About the role
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.
Responsibilities
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
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
Provide virtual behavioral health consultation and support to participants and staff across PPGNY, as appropriate and within role expectations
Participate in interdisciplinary case conferences regarding behavioral health needs
Recognize the boundaries of the role and refer participants for licensed psychotherapy, psychiatric evaluation, or higher levels of care when clinically indicated
Participate in street outreach, Mobile Health Center operations, health fairs, community events, and other engagement activities
Recruit, engage, and retain eligible participants
Connect participants to: HIV prevention and treatment services, PrEP and PEP, STI screening and treatment, Hepatitis C screening and linkage, Sexual and reproductive health care, Gender-Affirming Hormone Therapy (GAHT) referrals and support services, Primary care and preventive health services, Mental health services, Substance use treatment, Housing assistance, Food resources, Transportation assistance, Public benefits, Legal resources, Domestic violence services, Community-based organizations
Monitor referrals and ensure successful linkage to care whenever possible
Conduct follow-up with participants and partner organizations to support completed referrals and ongoing engagement
Adhere to organizational safety protocols while engaging participants in community, street outreach, mobile health, and field-based settings
Represent PSB and PPGNY professionally when working with participants, community members, partner agencies, and external stakeholders
Qualifications
Master’s Degree in Social Work from an accredited institution
Current New York State Licensed Master Social Worker required
LCSW preferred
Minimum of two years of experience in behavioral health, community health, HIV services, case management, care coordination, or a related field
Experience working with underserved communities
Experience providing crisis intervention, psychosocial support, safety planning, and care coordination
Knowledge of trauma-informed care, motivational interviewing, strengths-based practice, harm reduction principles, and health equity
Excellent communication, assessment, organizational, documentation, and problem-solving skills
Ability to work independently and collaboratively in fast-paced community, clinical, and mobile health environments
Proficiency with electronic health records, data systems, Microsoft Office applications, and virtual meeting platforms
Bilingual English/Spanish preferred