Social Worker

The Licensed Social Worker / Behavioral Health & Community Resource Coordinator is responsible for providing social work services, behavioral health support, care coordination, and community resource navigation for patients served by the FQHC. Conduct psychosocial assessments to identify patient needs, barriers to care, and social determinants of health. Provide short-term counseling, crisis intervention, supportive services, and case management. Assist patients with accessing community resources related to housing, food insecurity, transportation, utilities, employment, insurance coverage, and other social support services. Collaborate with medical, dental, behavioral health, and care management teams to develop and implement patient-centered care plans. Support patients experiencing chronic illness, behavioral health concerns, substance use disorders, domestic violence, trauma, or other complex challenges. Educate patients and families regarding available community resources and healthcare services. Facilitate referrals to behavioral health providers, specialty care providers, social service agencies, and community organizations. Monitor patient progress and follow up to ensure continuity of care and successful resource connection. Assist in identifying, enrolling, and engaging participants for grant-funded programs. Provide case management and support services for grant participants. Maintain required documentation and data collection for grant reporting and compliance. Assist with program outreach, participant recruitment, retention efforts, and community engagement activities. Track participant outcomes and support quality improvement initiatives. Collaborate with grant managers, program staff, and community partners to meet program objectives and deliverables. Participate in grant-related meetings, audits, monitoring activities, and reporting requirements. Develop and maintain relationships with community agencies, social service organizations, educational institutions, and other stakeholders. Serve as a liaison between patients, healthcare providers, and community resources. Participate in health fairs, outreach events, and community education activities as needed. Assist with addressing barriers to healthcare access and promoting health equity throughout the service area. Support population health initiatives and community needs assessment activities. Maintain accurate and timely documentation in the electronic health record (EHR). Ensure compliance with FQHC, HRSA, state, federal, grant, and organizational requirements. Protect patient confidentiality and adhere to HIPAA regulations. Participate in quality improvement and risk management activities. Other duties as assigned by management