Social Worker

Job Overview
The Social Worker at Health Reach serves as the frontline advocate and problem-solver for patients experiencing homelessness, providing direct psychosocial intervention, urgent response, navigation benefits, and housing assistance. This role is embedded within a fast-paced clinical environment and works in close partnership with primary care providers, nurses, and a care management team to address the complex, intersecting needs of patients who face housing instability, behavioral health challenges, and systemic barriers to care.

The Social Worker receives real-time handoffs from clinicians for urgent patient needs and independently manages a caseload of ongoing interventions. This position requires someone who thrives in a dynamic, high-volume setting and brings deep knowledge of community resources, public systems, and the practical skills needed to cut through bureaucratic obstacles on behalf of patients.

Responsibilities

Urgent Response and Clinical Collaboration

• Receives direct handoffs from medical and behavioral health clinicians for urgent psychosocial interventions, including housing crises, benefits emergencies and safety concerns.
• Collaborates with clinical staff to help conduct rapid psychosocial assessments for patients in crisis, determining appropriate interventions and connecting patients to immediate resources.
• Manages an active caseload of patients requiring ongoing social work intervention, including follow-up on referrals, documentation of progress, and coordination with clinical staff.
• Collaborate with other care management team members to ensure seamless coordination between clinical care and community-based support.

Housing Assistance and DHS Navigation

• Assist patients with navigating the DHS system, including shelter placement, transfers, fair hearings, and resolution of DHS-related barriers.
• Supports patients in pursuing permanent housing through knowledge of supportive housing applications, community partners, Section 8 vouchers, rental assistance programs, and rapid rehousing pathways.
• Advocates directly with shelter staff, DHS, and housing providers to resolve patient issues and expedite placements.

Public Benefits and Entitlements

• Assist patients with applications for and maintenance of Medicaid, Medicare, SSI/SSDI, SNAP, public assistance, and other entitlement programs.
• Help patients navigate HRA, Social Security Administration, and other government agency processes.
• Identifies and resolves barriers to benefits access, including lost documentation, expired benefits, sanctions, and eligibility issues.

Adult and Child Protective Services

• Files reports with Adult Protective Services (APS) and Child Protective Services (CPS) as mandated, and coordinates follow-up with investigating agencies.
• Collaborates with APS/CPS caseworkers to support patients who are subjects of investigations, ensuring patient safety while maintaining therapeutic rapport.

Community Liaison and Resource Navigation

• Maintains broad, current knowledge of community-based organizations, social service agencies, legal aid providers, substance use treatment programs, mental health resources, and other supports relevant to patients experiencing homelessness.
• Build and maintain working relationships with external agencies and service providers to facilitate warm handoffs and effective referrals.
• Educates clinical team members on available community resources, public benefit programs, and systemic issues affecting patients experiencing homelessness.

Documentation and Compliance

• Documents psychosocial assessments, interventions, care plans, and referral outcomes in the electronic health record in accordance with organizational and regulatory requirements.
• Involves patients and families in treatment planning and documents consent and participation appropriately.
• Complete all required clinical and administrative documentation in a timely manner.

Professional Development

• Maintains current knowledge of social work best practices, community resources, and policy changes through continuing education, supervision, and professional development activities.
• Participate in team meetings, case conferences, and quality improvement activities.

Experience

• Proven experience in social work or behavioral health settings within hospitals or community clinics.
• Demonstrated expertise in psychotherapy modalities including cognitive behavioral therapy, psychodynamic therapy, motivational interviewing, and group therapy.
• Experience working with children, adolescents, geriatrics, or individuals with developmental disabilities or autism spectrum disorders.
• Familiarity with medical documentation practices and medical terminology related to mental health diagnoses such as ICD coding systems.
• Background in crisis management, case management, intake procedures, and diagnostic evaluation processes.
• Knowledge of working within HIPAA guidelines to ensure patient privacy and confidentiality at all times.
• Prior involvement in clinical research or data collection initiatives related to mental health or behavioral sciences is advantageous. Join our team to provide compassionate mental health services that foster resilience and improve lives through expert clinical care and dedicated support.

Clinical Therapy (Optional)

For social workers interested in providing direct therapeutic services, Health Reach offers the opportunity to carry a supervised therapy caseload under the clinical supervision of a Licensed Clinical Social Worker (LCSW). This is not a requirement of the position but is available for social workers seeking to develop or maintain clinical skills and accrue supervised hours toward licensure.

Qualifications

Required:

• Master’s degree in social work (MSW) from an accredited program.
• LMSW licensure (State of New York) or ability to obtain within 90 days of hire.
• Demonstrated knowledge of DHS, HRA, and public benefits systems.
• Experience working with individuals experiencing homelessness or housing instability.
• Familiarity with APS and CPS reporting requirements and processes.
• Strong interpersonal, written, and verbal communication skills.
• Ability to work effectively in a fast-paced, high-volume clinical environment with frequent interruptions and shifting priorities.

Preferred:

• Two to five years of experience in a health care, homeless services, or community-based social services setting.
• Experience in a Federally Qualified Health Center (FQHC) or Health Care for the Homeless (HCH) program.
• Established network of community contacts across housing, behavioral health, legal, and social service sectors.
• Bilingual (English/Spanish) a plus.
• LCSW licensure or interest in pursuing LCSW under supervision.

Work Environment

This is a full-time, on-site position based in Health Reach’s clinical offices. The work environment is busy, collaborative, and patient centered. The Social Worker should expect a varied daily routine that includes scheduled caseload work alongside unplanned urgent interventions. Flexibility, resilience, and commitment to meeting patients where they are—both literally and figuratively—are essential to success in this role.

Hours and Benefits

JOB TYPE: Full-time

PAY RANGE: $31.25- $36.10 Hourly

EXPECTED HOURS: 40 hours per week

BENEFITS:

· 401(k)

· 401(k) match

· Dental Insurance

· Vision Insurance

· Medical Insurance

· Employee Assistance Program

· Paid Personal Time

· On-the-job training

SCHEDULE:

· Monday through Friday

· 8:00 – 4:30pm

WORK SETTING:

· In-person/Office

Regional Health Reach is an Equal Opportunity Employer. We believe in equal opportunity for all and are committed to ensuring all individuals have equal opportunity relating to recruitment, employment, career development and advancement, promotion, and retirement and are based solely on merit, without regard to all legally protected classes, including, but not limited to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability and genetic information (including family medical history) or any other status protected by federal, state or local law.

Regional Health Reach is also committed to providing reasonable accommodations to qualified individuals with a disability so that an individual can perform job-related duties. If you are interested in applying for an employment opportunity and require special assistance or an accommodation to apply due to a disability, please contact our Director of Operations at [email protected].

Pay: $31.25 - $36.10 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Education:

• Master's (Required)

Experience:

• Social work: 1 year (Required)

Work Location: In person