Fenway Health is funded to provide medical case management and navigation services for people living with HIV (PLWH) to help them engage in medical care and achieve viral suppression. the High Acuity Community Health Worker Program is designed to help PLWH in these areas by providing intensive, wraparound short-term case management and navigation services. Enrolled clients participate in an assessment of service needs, individualized care planning, navigation to timely and coordinated medical and support services, treatment adherence counseling, and client specific referrals and advocacy. Funded by the Boston Public Health Commission and the MA Department of Public Health, this program works with clients who are least likely to be retained in care and provides enhanced outreach and field contact to address barriers to engagement in care and adherence to medication regimens.

Reporting to the Administrative and Clinical managers for the High Acuity Case Management Program, the High Acuity Social Worker plays a key role in overseeing the team of community health workers, who will each have their own caseloads. This role ensures that PLWH enrolled in the High Acuity Community Health Worker Program are appropriately assessed and triaged. Once the cases are assigned to a community health worker, the High Acuity Social Worker oversees the service planning and service delivery process with the goal of stabilization and engagement in medical services. The High Acuity Social Worker is skilled in providing and implementing low threshold, intensive case management services utilizing a harm reduction philosophy.

Representative Duties:

Triage and case assignment

• Initiates initial assessments including Public Health intake and Ryan White eligibility screening
• Assigns cases to the most appropriate CHW based on assessment and needs of the client
• Provides linkage to culturally competent resources and treatment for those who are experiencing homelessness, active substance users, recent immigrants, people of color, and/or people who identify as part of the LGBTQ community.
• Responds to requests from program staff for routine and crisis interventions and warm handoffs

Service Plan Development and Oversight

• Oversees and tracks the planning and updates of each service plan for enrolled clients
• Ensures clients are receiving highly effective care, services, and communication from the CHWs
• Coaches CHWs in supporting clients in employing a range a of risk reduction and self-sufficient skills

Direct Supervision of CHW’s

• Provides support to CHWs around interactions with clients, modelling appropriate boundaries and approaches to client care
• Holds routine 1:1 direct supervision with CHWs and provides case review and coaching to ensure clients are receiving highly effective services
• Monitors enrollment and discharge of caseloads and capacity of CHWs
• Supports CHWs with appropriate training including safety planning and crisis management

Maintain small caseload when appropriate

• Provides clients with easily accessible and low-threshold services
• Provides clinical and supportive services to clients in community, office based, and remote settings, as determined by client care and departmental needs

Contribute to program growth and development

• Work alongside program leadership to develop programmatic workflows with an eye for process improvement
• Develops/maintains collaboration with a wide range of resources and treatment options within the Greater Boston area to refer and link clients, as applicable
• Holds client case conferencing meets for CHWs to network and practice problem solving in team setting
• Upholds program expectations around grant-related deliverables
• Work with program leadership to develop and facilitate HIV related support groups

Performs and completes clinical documentation/administrative tasks accurately and in a timely manner

• Documents each client interaction in our EPIC system
• Oversees and reviews initial service plans, service plan updates, EPIC notes, and discharge summaries according to funder requirements, department standards and in accordance with Fenway policy
• Attends to the requirements for obtaining and tracking Ryan White and Public Health/ARCH eligibility and timely reassessments of needs
• Sets program expectations for document collection and CHW collaboration
• Provides consultation to, and collaborates with, other care providers that constitute a client’s health care or public health team

Meets Agency Participatory Expectation

• Participates in regularly scheduled supervision
• Participates in staff meetings, training, and continuing education activities of the Fenway Health Prevention and Nursing Departments.
• Adheres to all agency and department policies and procedures
• Adheres to the highest principles of patient and client confidentiality
• Attends and actively participates in department and agency meetings, in-services, and trainings
• Maintains professional competence necessary to perform job responsibilities; maintain and provide agency with credentials and continuing education activities as required

Performs other duties as related

Requirements

• Masters in social work
• At least two years of relevant experience
• Minimum of two years of supervisory experience
• Commitment to reducing barriers to accessing medical care and supportive services with low-threshold and risk reduction models
• Ability to complete documentation in a timely manner, and maintain up to date client care documentation required
• Flexibility, adaptability, and ability to multitask required
• Experience and demonstrated competence working with the following populations: LGBTQ, people of color, immigrants, people living with or at risk for HIV/AIDS and/or medical issues, trauma, substance use, homelessness, and mental illness
• Capacity to work independently and as part of interdisciplinary team
• Ability to work harmoniously and effectively with colleagues, patients, clients, and vendors across the spectrum of diversity, including but not limited to race, ethnicity, color, gender identity, sexual orientation, age, socio-economic status, national origin, and immigrant status, religious or spiritual identity, disability (physical, mental, emotional, and developmental), veteran status, and/or limited English proficiency.
• Willingness to contribute towards Fenway’s efforts in becoming an anti-racist organization and promoting a culture dedicated to ongoing development in service of humility, equity, diversity, inclusion, and belonging, where differences are acknowledged and valued.

Preferred Qualifications:

• Experience working with clients who have substance use issues and knowledge of and commitment to using a harm reduction, motivational interviewing, trauma informed, strengths-based and client centered approaches
• Experience working with an ethnically, culturally, and racially diverse work staff
• Experience in clinical screening assessment/evaluation

We offer competitive salaries, and for those who qualify, an excellent benefits package; including comprehensive medical and dental insurance plans, and a retirement plan with employer match. We also provide 12 paid holidays, paid vacation, and more.

LGBTQIA+ identified persons, Black, Indigenous, and other people of color (BIPOC), and individuals from other historically underrepresented communities are strongly encouraged to apply.