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. 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. 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. Community Outreach, Navigation & Linkage to Care — 15% 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. Documentation, Data Collection & Grant Compliance — 20% Complete timely, accurate, and comprehensive documentation in the electronic health record and other required systems. Maintain participant records in required databases and documentation platforms. Document assessments, care plans, referrals, interventions, participant contacts, linkage outcomes, barriers, and follow-up activities. Maintain documentation in accordance with organizational, regulatory, and grant-funded program requirements. Ensure records are complete, accurate, audit-ready, and reflective of services provided. Collect and report program data in accordance with grant requirements and funder expectations. Participate in documentation reviews, quality assurance activities, monitoring visits, audits, and corrective action processes