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About the Role

The Community Outreach Social Worker is a member of the Project Street Beat (PSB) interdisciplinary team, providing comprehensive case management, psychosocial support, behavioral health screening, crisis assessment, care coordination, and advocacy to individuals facing healthcare barriers. This role engages participants in community, mobile health, and clinical settings, collaborating with partners to improve health outcomes, reduce health disparities, and increase access to equitable, person-centered care for populations disproportionately impacted by health inequities.

Responsibilities

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, and 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.

Requirements

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.
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.
Proof of immunization or immunity to certain communicable diseases (including influenza during the flu season and Covid-19) and testing for tuberculosis.

Skills

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
Microsoft Office applications
Virtual meeting platforms

Location

Region 1

Work Type

Mobile Health Center operations
Virtual behavioral health support
Community-based settings
Health centers
Participant homes
Shelters
Partner agencies
Outreach locations
Field-based settings

Experience Level

Minimum of two years of experience

Education Level

Master’s Degree in Social Work
New York State Licensed Master Social Worker
LCSW preferred

Salary/Compensations

$78,097.50 - $78,097.50 a year

Benefits

Generous PTO and holiday schedule
Medical, dental and vision coverage options for you and eligible dependents
FSA, HSA, Commuter pre-tax reimbursement funds
Short- and Long-Term Disability, Free Basic Life and AD&D
401(k) Retirement Plan with Safe Harbor contributions after 1 year of employment

About the Company

Planned Parenthood of Greater New York (PPGNY) is a leading provider, educator, and advocate of sexual and reproductive health care in New York State.
PPGNY provides a wide-range of family planning services at our brick-and-mortar health centers and mobile care units.
We care for everyone regardless of their immigration status, zip code or ability to pay.
PPGNY’s education and outreach programs are backed by medically accurate, evidence-based information that allows people to make informed decisions about their health and future.
As a voice for reproductive freedom, PPGNY supports legislation and policies that ensure all New Yorkers have access to the full range of reproductive health care and education.
At PPGNY, we provide the absolute best care to our patients and our communities through innovative health care delivery and education programming.
We care for everyone who walks through our doors regardless of insurance, ability to pay or immigration status.
As a leading voice for reproductive freedom, PPGNY fiercely advocates for policies to ensure that all New Yorkers will have access to the full range of reproductive health care services and information.

Equal Opportunity

PPGNY is committed to diversity, equity, and inclusion.
We believe we are most impactful when people with a wide range of backgrounds, experiences, and identities come together with common purpose.
We encourage candidates from all backgrounds to apply.