The Licensed Clinical Social Worker (LCSW), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage and Family Therapist (LMFT), Associate Social Worker (ASW), Associate Professsional Clinical Counselor (APCC) or Associate Marriage and Family Therapist (AMFT) , is a key member of the primary care interdisciplinary team, provides services for patients with complex care needs. This position conducts patient outreach, engagement and psychosocial service assessment, assists in developing a patient-centered care plan, is the lead implementer of Enhanced Case Management (ECM) and coordinates service referrals and delivery. The social worker meets clients in home, clinic, or community as appropriate or required by the specific program/site. The LCSW/LPCC/LMFT/ASW/APCC/AMFT provides services to specific populations that have multiple complex health and social services needs and often provides care outside of a traditional health center setting, such as home visits, hospitals, supportive housing sites, encampments and shelters. In addition they provide comprehensive housing navigation support to clients.

This is a grant funded, full time, benefit eligible position. 

This is a union position. Salaries and benefits are set by a collective bargaining agreement (CBA), and an employee in this position must remain a member in good standing of the union. 

About us:

As a Federally Qualified Health Center in Northern California with over 45 years of dedicated service to the community, LifeLong serves over 66,000 patients in the East Bay Area's socio-economically underserved regions. We provide medical, dental, behavioral health, and school-based services at more than 15 primary care sites across Oakland, Berkeley, and West Contra Costa County. From opening a residential respite program for homeless persons discharged from hospital to offering free testing to the community, we are innovative and responsive to our times' social and medical needs. We provide an inclusive workplace that promotes and values diversity and with which our patients can identify. To this end, we seek candidates who reflect the diversity of the East Bay communities we serve.

Benefits:

We offer a competitive annual salary of $68,000-$72,000 for ASW/AMFT/APCC, $100,000-$120,000 for LCSW/LMFT/LPCC, depending on years since licensed, and excellent benefits: medical, dental, vision, Flexible Spending Accounts, dependent and domestic partner coverage, 403(b) retirement savings plan, and loan repayment programs. LifeLong is a qualified site for federal and state loan repayment programs (HPSA score is 16). Acceptance rates may vary year to year based on funding levels and the number of applicants.

• Outreach, via telephone and in person at LifeLong, community and residential sites, to patients who meet case management program eligibility criteria or are prioritized by LifeLong for this service
• Proactively meet and engage with patients to build effective relationships and assess strengths and needs through use of standard intake, screening tools, and health, and social services records review
• Actively involve patients and caregivers, as appropriate, in designing and delivering services, including development of care plans, assuring alignment with patients’ values and expressed goals of care
• Provide and facilitate referrals for internal and external resources, and collaborate with the patient to complete required applications, forms, or releases of information
• Maintain a patient caseload in accordance with LifeLong standards for the specific population served or site requirements
• Utilize data registries and reports to manage caseload, meet program requirements, maintain grant deliverables, and promote high quality care
• Provide health education and training to patients, including but not limited to, harm reduction and disease risk-mitigation strategies that empower patients to manage their own health and wellness (e.g. overdose prevention, mitigating spread of communicable diseases)
• Assist patients with accessing and retaining public benefits and insurance (e.g. MediCal, SSI/SSDI, CalFresh, General Assistance), and affordable/subsidized housing
• Respectfully and routinely communicate with patients, their care team members, external partners, and identified social supports
• Maintain knowledge of patients’ medical/behavioral health treatment plans and facilitate utilization of services by providing resources such as accompaniment, transportation, in-home care, reminder calls etc.
• Participate in team meetings to coordinate care, support patient goals, and reducing barriers to accessing services
• Provide case management services to patients with multiple complex acute or chronic medical or behavioral health conditions (e.g. HIV/AIDS, Hep C, congestive heart failure, severe diabetes, severe hypertension, psychosis, pregnancy, and homelessness)
• Provide general housing case management services that includes document readiness, housing problem solving, and assessments for Coordinated Entry System
• Assess patients to identify cognitive and/or behavioral health needs and provide brief interventions and short-term support using standardized tools and effective approaches for patient care
• Co-facilitate patient groups
• Provide intensive case management to a caseload size in accordance with site or program standards focusing on a subset of the highest acuity patients
• Provide specialized housing navigation services to patients who are matched to a housing resource through Coordinated Entry System
• Lead crisis intervention response, de-escalation procedures, notification of the local mental health department and/or crisis response team, and follow-up care
• Provide and document billable services to eligible populations that result in revenue generation for LifeLong
• Advocate on behalf of patients to get their needs met and/or support patients to learn advocacy strategies for themselves.
• Keep current on community resources and social service supports to effectively serve the target population
• Document patient contacts/services in required data systems (EHR, HMIS etc.) according to LifeLong policy
• Specific activities may vary depending on the requirements of the program and funder.
• Promote diversity, equity, inclusion, and belonging in support of patients and staff
• Represent LifeLong positively in the community and advocate on behalf of underserved populations

• Commitment to working directly with low-income persons from diverse backgrounds in a culturally responsive manner
• Commitment to harm reduction, recovery, housing first, age-friendly and patient centered care
• Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change while maintaining a positive attitude
• Excellent interpersonal, verbal, and written skills
• Ability to prioritize tasks, work under pressure, and complete assignments in a timely manner
• Ability to seek direction/approval on essential matters, yet work independently, using professional judgment and diplomacy
• Works well in a team-oriented environment
• Conducts oneself in external settings in a way that reflects positively on your employer
• Ability to be creative, mature, proactive, and committed to continual learning and improvement in professional settings

Job Requirements

• Current and valid California LCSW, LMFT, LPCC license, or ACSW, AMFT or APCC registration with the California Board of Behavioral Sciences.
• Working knowledge of the local behavioral health service system.
• Familiarity with evidence-based practices for behavioral health disorders.
• Experience in clinical case management and harm reduction.
• Proficient skills using Microsoft Office applications like Word, Excel, and Outlook, as well as the ability to work in and/or manage databases
• Access to reliable transportation with current license and insurance

Job Preferences

• Experience relative to working with people experiencing homelessness (e.g. formerly homeless, social or behavioral health services consumer, criminal justice system involvement, foster care involvement)
• Bilingual English/Spanish speaking