Provide intensive case management for patients in the Bridge Program
Welcome new patients, screen for non medical drivers of health needs, engage as needed
Develop individualized treatment plans and psychosocial goals for short- and long-term care plans by assessing individual needs, strengths, barriers and readiness to change
Provide crisis intervention services (assessment, evaluation of risk, referral and follow up)
Effectively de-escalate heightened situations with patients experiencing trauma, exacerbated mental health symptoms, and behavioral complexity
Provide goal oriented and short oriented services (engagement, case management, counseling linkage) with complex psychosocial needs
Educate patients on available community resources and teach appropriate expectations and follow-through
Help patients identify and manage challenges in navigating health and government benefits
Accompany patients to appointments as needed and assist with transportation coordination
Assist patients directly or indirectly with housing survey (Coordinated Assessment) and discharge planning
Work with housing specialists and partner agencies to identify and address psychological, social and medical needs and coordinate referrals for housing programs
Participate in weekly case conference with multidisciplinary bridge team and collaborate with community resources
Assist Bridge team in picking up medications and other support services
Other duties as assigned
Requirements
Bachelor's degree in Social Work or related field (higher degree accepted)
Required Experience (Less than 1 year): Internship or work in field related to social work, case management, or counseling individuals in crisis/trauma situations
Demonstrated knowledge of community resources available and how to access resources for the benefit of clients
High level of skill at building relationships and providing excellent customer service
High level of problem-solving skills
Strong attention to detail and accuracy
Excellent verbal and written communication skills
Skilled in crisis management and de-escalation
Demonstrated success in collaborating with multidisciplinary team members