Community Outreach Social Worker

Position Summary

Essential Functions

• 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.

• 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.

• 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.

• 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 as needed.
• Assist with data validation, grant reporting, and program-performance tracking.
• Ensure compliance with organizational policies, regulatory requirements, confidentiality standards, and funding expectations.
• Participate in continuous quality improvement activities using program performance data.

• Participate in interdisciplinary case conferences and team meetings.
• Collaborate with providers, navigators, outreach staff, behavioral health professionals, care teams, and community partners.
• Participate in quality improvement initiatives and program planning.
• Support implementation of organizational, clinical, integrated care, and grant-funded initiatives.
• Attend required meetings, trainings, supervision, and professional development activities.
• Maintain knowledge of trauma-informed care, harm reduction, motivational interviewing, HIV prevention and care, sexual and reproductive health, community resources, and health equity practices.
• Perform other duties as assigned.

Population Served

• Individuals living with HIV
• Individuals at risk for HIV
• Individuals seeking PrEP and PEP services
• Individuals diagnosed with sexually transmitted infections
• Individuals diagnosed with hepatitis C
• People who use drugs
• Individuals experiencing homelessness or housing instability
• Individuals with behavioral health needs
• Justice-involved individuals
• LGBTQ+ communities
• Individuals seeking or receiving gender-affirming care
• Adolescents and young adults
• Adults experiencing barriers related to poverty and other social determinants of health

Performance Expectations

• Maintain an assigned caseload in accordance with program expectations.
• Meet established productivity, outreach, engagement, and linkage targets.
• Complete timely psychosocial assessments and care plans.
• Complete documentation within established timeframes.
• Successfully link participants to medical, behavioral health, sexual and reproductive health, and supportive services.
• Maintain accurate, complete, and audit-ready documentation.
• Meet grant-specific deliverables, performance benchmarks, and reporting requirements.
• Participate in interdisciplinary care coordination and case conferences.
• Maintain participant engagement, follow-up, and retention.
• Support Project Street Beat’s strategic goals through collaboration, quality improvement, and continuous learning.
• Demonstrate professionalism, sound judgment, and adherence to organizational policies and safety protocols.

Travel Requirements

Core Competencies

• Case Management
• Psychosocial Assessment
• Behavioral Health Screening
• Crisis Assessment and Intervention
• Safety Planning
• Trauma-Informed Care
• Harm Reduction
• Motivational Interviewing
• Care Coordination
• Community Resource Navigation
• Integrated Care Collaboration
• Cultural Humility
• Health Equity
• Documentation and Data Integrity
• Grant Compliance
• Quality Improvement
• Customer Service
• Communication
• Accountability

Minimum Qualifications

• Master’s Degree in Social Work from an accredited institution.
• Current New York State Licensed Master Social Worker required.
• LCSW preferred.
• Minimum of two years of experience in behavioral health, community health, HIV services, case management, care coordination, or a related field.
• Experience working with underserved communities.
• Experience providing crisis intervention, psychosocial support, safety planning, and care coordination.
• Knowledge of trauma-informed care, motivational interviewing, strengths-based practice, harm reduction principles, and health equity.
• Excellent communication, assessment, organizational, documentation, and problem-solving skills.
• Ability to work independently and collaboratively in fast-paced community, clinical, and mobile health environments.
• Proficiency with electronic health records, data systems, Microsoft Office applications, and virtual meeting platforms.

Preferred Qualifications

• Experience working in HIV prevention or HIV care.
• Experience working in sexual and reproductive health.
• Experience supporting referrals related to Gender-Affirming Hormone Therapy or LGBTQ+ health services.
• Experience working in mobile health, street outreach, or community-based public health programs.
• Experience with grant-funded public health programs.
• Bilingual English/Spanish preferred.

Working Conditions and Physical Requirements

This position requires work in community-based settings, mobile health environments, health centers, participant homes when appropriate, shelters, partner agencies, and outreach locations. The position requires frequent travel to various locations, occasional evening and weekend work, and the ability to work both independently and collaboratively in fast-paced environments. The role may require:
• Standing and walking for extended periods during outreach and community events.
• Working outdoors in variable weather conditions.
• Transporting, setting up, and breaking down outreach materials and supplies.
• Working in mobile health settings and community locations with varying environmental conditions.
• Engaging participants in public spaces, shelters, community-based organizations, and other field-based environments.
• Following all organizational safety protocols related to outreach, mobile health operations, infection prevention, emergency response, and workplace safety.