Social Worker 3, Clinical Supervisor, HEAT Program

The Department of Pediatrics at SUNY Downstate Health Sciences University is seeking a full-time TH Social Worker III, Clinical Supervisor, HEAT Program.

Job Summary

The TH Social Worker III is an integral member of the hospital’s multidisciplinary healthcare team, providing professional social work services to patients, families, and caregivers. The incumbent assesses psychosocial, emotional, socioeconomic, and environmental needs; develops and implements appropriate interventions; and collaborates with the interdisciplinary care team to support patient well-being, continuity of care, and safe, timely discharge planning.

The Social Worker provides crisis intervention, supportive counseling, patient and family education, advocacy, and referrals to community resources while assisting patients and families in addressing challenges associated with illness, hospitalization, treatment, and transitions of care. Services may be provided across inpatient, outpatient, emergency, pediatric, and other specialty care settings, consistent with professional licensure, assigned responsibilities, and hospital policies.

The Department of Pediatrics at SUNY Downstate Health Sciences University is seeking a full-time TH Social Worker III for its Health & Education Alternatives for Teens (HEAT) Program. The position supports adolescents and young adults living with HIV or at elevated risk, including underserved and LGBTQ youth in Brooklyn, through psychosocial assessment, supportive counseling, care coordination, and multidisciplinary collaboration.

Key Responsibilities & Duties

• Conduct psychosocial assessments of patients and families to identify emotional, behavioral, social, financial, and environmental factors affecting health, treatment, recovery, and discharge planning.
• Develop, implement, and evaluate individualized psychosocial intervention plans in collaboration with patients, families, caregivers, and the interdisciplinary healthcare team.
• Provide supportive counseling, crisis intervention, grief and bereavement support, and appropriate psychosocial interventions within the scope of professional licensure and supervision.
• Participate in interdisciplinary rounds, multidisciplinary huddles, case conferences, and care planning meetings to address psychosocial concerns and discharge needs.
• Collaborate with physicians, nurses, case managers, rehabilitation professionals, and other healthcare providers to facilitate coordinated, patient-centered care.
• Assist with safe, appropriate, and timely discharge plans, including coordination of home care, durable medical equipment (DME), community services, and post-acute care placements.
• Coordinate with Care Management and external agencies on referrals and placements to skilled nursing facilities, subacute rehabilitation, long-term care, and other appropriate settings.
• Identify psychosocial barriers that may contribute to avoidable admissions, prolonged length of stay, delayed discharge, or preventable readmissions; collaborate with the team to address them.
• Educate and advocate for patients and families regarding treatment-related needs, financial assistance, public benefits, healthcare coverage, and community support programs.
• Assist patients and families in accessing appropriate Medicare, Medicaid, federal, state, and community resources.
• Assess and respond to suspected child abuse, elder abuse, neglect, domestic violence, and other vulnerable patient situations; complete required reporting and referrals in accordance with law and hospital policy.
• Coordinate, as appropriate, with the Administration for Children’s Services (ACS), Adult Protective Services (APS), and other community agencies.
• Facilitate patient and family conferences to address psychosocial concerns, treatment decisions, discharge planning, and continuity-of-care needs.
• Assist with guardianship referrals in collaboration with Risk Management, Legal Affairs, and other appropriate departments.
• Provide psychosocial assessment, crisis intervention, and discharge planning support in emergency and other assigned clinical settings.
• Provide age-appropriate psychosocial support and care coordination for pediatric, adolescent, adult, and geriatric populations, as applicable to the assigned service.
• Document assessments, interventions, referrals, and care coordination accurately, promptly, and confidentially in the electronic medical record; complete case closure within departmental timeframes.
• Support organizational goals for effective transitions of care, appropriate utilization of resources, and length-of-stay management through interdisciplinary collaboration.
• Participate in professional development, departmental meetings, in-service education, and quality improvement initiatives.
• Comply with applicable federal and state regulations, professional standards, accreditation requirements, and hospital policies.
• Perform other duties as assigned, consistent with professional licensure, qualifications, and institutional needs.

Department-Specific Responsibilities – HEAT Program

• Provide direct psychosocial support and care coordination to adolescents and young adults living with HIV or at elevated risk, with an emphasis on underserved and LGBTQ youth in Brooklyn.
• Conduct comprehensive biopsychosocial assessments and screen for mental health, social, and behavioral concerns; coordinate psychiatric referrals when indicated.
• Provide supportive counseling, crisis intervention, and appropriate individual, couples, or family services within the authorized scope of licensure and supervision.
• Collaborate with physicians, nurses, behavioral health professionals, case managers, and other providers to implement coordinated, individualized care plans.
• Participate in weekly multidisciplinary case conferences and monthly HEAT Program meetings.
• Conduct clinical and psychosocial assessments for participants in behavioral interventions and support evidence-based, trauma-informed and affirming care.
• Provide case consultation, staff mentoring, and programmatic guidance to social work and case management personnel as authorized; formal clinical supervision duties require separate classification and licensure review.
• Support quality improvement activities, mental health-related grant deliverables, clinical documentation standards, and compliance with hospital and funding agency requirements.

Required Qualifications

• Master’s Degree in Social Work (MSW) from a program accredited by the Council on Social Work Education (CSWE), or equivalent education accepted by the New York State Education Department for social work licensure.
• Current New York State licensure as a Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW).
• Knowledge of professional social work principles and practices, including psychosocial assessment, supportive counseling, crisis intervention, patient advocacy, and care coordination.
• Strong interpersonal, communication, organizational, and problem-solving skills, with the ability to collaborate effectively with multidisciplinary healthcare teams.
• Ability to provide culturally responsive, patient-centered services while maintaining professional standards, confidentiality, and accurate clinical documentation.
• Or, a satisfactory equivalent combination of experience, education and training.

Preferred Qualifications

• 1+ year of professional social work experience in a hospital, healthcare, behavioral health, or related clinical setting.
• Experience with hospital discharge planning, interdisciplinary care coordination, and community resource referrals.
• Familiarity with Medicare, Medicaid, managed care, and applicable healthcare regulations and accreditation standards.
• Experience using electronic medical records (EMR/EHR) for clinical documentation and care coordination.
• Certified Case Manager (CCM) certification.

Department-Specific Preferred Qualifications – HEAT Program

• Experience providing social work or behavioral health services to adolescents and young adults living with HIV or at elevated risk.
• Knowledge of HIV-related psychosocial needs, psychiatric referral resources, and evidence-based behavioral interventions.
• Experience with multidisciplinary case conferences, program quality improvement, grant-funded services, or staff mentoring.
• Experience working with LGBTQ youth and underserved populations using culturally responsive, trauma-informed, affirming approaches.
• Experience providing counseling and psychosocial interventions in adolescent health, HIV care, or community-based behavioral health settings.