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About the Role

The Clinical Social Worker (CSW) provides comprehensive case management services to patients of Lyon-Martin. Working closely with a multidisciplinary team, the CSW assesses patient needs, coordinates care, and connects patients to medical, mental health, and social services. They are responsible for providing clinically appropriate Case Management and Crisis Intervention services, including substance use disorder counseling, crisis intervention and de-escalation, safety planning, and appropriate internal/external referrals. The CSW must maintain a high degree of professional competence, ethical standards, and collaborate effectively within an integrated health care team.

Responsibilities

Conduct comprehensive intake assessments, including medical, psychological, and social factors, to identify patient needs and goals, as well as social determinants of health.
Develop individualized care plans that address the physical, mental, and social well-being of the patient.
Collaborate with the patient, their family, and their care team to establish goals and interventions.
Serve as a liaison between patients, healthcare providers, and external organizations to ensure coordinated care and shared understanding of care plans.
Assist patients with scheduling appointments, arranging transportation, interpretation access, and navigating the healthcare system.
Provide and coordinate referrals and assist with paperwork for wraparound services.
Provide immediate triage and intervention for patients presenting with suicidal ideation or mental health crises.
Conduct risk assessments to determine the level of care required.
Develop safety plans with patients in crisis, including follow-up care and monitoring.
Maintain open communication with the care team to ensure patient safety and well-being.
Collaborate with the team to ensure access to long-term care and recovery.
Lead restorative justice and accountability conversations with clients who break Lyon-Martin’s community agreements.
Facilitate discussions about unacceptable behavior, harm caused, and work with the client to agree on a commitment to appropriate behavior.
Communicate consequences clearly if behavior is repeated and follow through on those consequences.
Maintain accurate, timely documentation of all case management activities in the EHR, Epic.
Complete all visit notes and respond to in-basket messages within 72 hours.
Regularly monitor patient progress and update care plans.
Meet productivity and quality indicator benchmarks, maintaining a caseload of a minimum of 3 patients per half day.
Adhere to all FQHC, federal, state, and city regulations, including HIPAA.
Participate in weekly Case Management Team Meetings, Collaborative Care Meetings, All Staff Meetings, and subcommittee meetings.
Engage in professional development to stay informed on best practices.
Engage with clients who have high no-show rates or utilize emergency care at high rates to support access to care.
Facilitate group(s) therapy to foster safety, consistency, and connection to community.
Accompany clients to referral or social services appointments as needed.

Requirements

Graduation from an accredited school of social work.
Licensed in California as an LCSW or ASW.
Extensive knowledge of Bay Area public benefit resources and networks.
Excellent de-escalation and non-violent communication skills.
Experience safety planning for individuals in crisis, particularly those with suicidal ideation.
Experience mediating using restorative justice principles and practices; ability to facilitate accountability conversations.
Strong interpersonal skills, with an emphasis on empathy and patient-centered care.
Culturally sensitive/humble and able to work with diverse populations.
Strong proficiency with EHR systems, Microsoft Office applications, specifically Word, Outlook, internet applications, zoom, computer technology, and phone use.
Experience working with lesbian, bisexual, transgender, gender non-conforming, non-binary, and intersex communities, populations with varying disabilities, racial, ethnic and cultural backgrounds and economic statuses, people who do sex work, those experiencing homelessness, people who have challenges with severe mental illness, people who use drugs, those of with a history of incarceration, people of varying ages.
An interest in and commitment to accessible gender affirming health care, abortion and primary care for marginalized populations.
LCSW (Preferred)
Bilingual Spanish/English fluency; other bilingual or multilingual fluency (Preferred)
Experience using Epic (Preferred)
At least 2 years of experience providing case management in a community clinic or hospital setting (Preferred)

Skills

Mission-driven
Teamwork
Communication
Reliability
Customer Service
Computer Literacy
Tolerance for Stress, Ambiguity, and Change
Attention to Detail
Decision Making
Integrity and Ethics
Presentation Skills
Accountability
Follow Through
Cultural Humility and Sensitivity
Intelligence
Creativity/innovation
Enthusiasm
Work ethic
Case Management
Crisis Intervention
Restorative Justice
EHR systems
Microsoft Office Suite
MS Excel
MS Word
MS PowerPoint
Bilingual Spanish/English

Location

San Francisco, CA

Work Type

Hybrid
Full-time

Experience Level

Associate
Licensed
2+ years of case management experience (Preferred)

Education Level

Graduation from an accredited school of social work
LCSW
ASW

Salary/Compensations

$102,297.29 per year (Licensed)
$80,973.40 per year (Associate)

Benefits

100% employer paid Platinum level medical plans for employees and their minor dependent(s)
Premium dental, vision, life and acupuncture/chiropractic plans
Up to 3% 403b match
Access to pre-tax health, dependent care and commuter benefits
Professional development funds

About the Company

The mission of Lyon-Martin Community Health Services is to provide high quality, compassionate and trauma-informed medical, gynecological, and mental health care services to trans, non-binary, gender non-conforming, and intersex communities and cis-gender women with specific sensitivity to LGBQA+ sexual orientation, disability, size, race, ethnicity, and language, regardless of immigration status or ability to pay.
We aim to eliminate health inequities for our communities by rooting our clinical practice in core foundational intersectional frameworks of anti-racism, self-determination, harm reduction, and reproductive and disability justice.
As a community clinic, we believe our communities are best served by and for us; that’s why community outreach, engagement, and leadership development are central to our mission of community care and mutual aid.
Lastly, we commit to increasing access to culturally responsive care beyond our walls through provider training and education, and policy advocacy.