Community Outreach Social Worker

Position Summary

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.

Essential Functions

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.