About CityLife: CityLife Neighborhood Clinics… Improving health block by block… It’s a movement!  CityLife is changing how members should think of primary care. Like the old family doctor, primary care is the first place to go for all your health needs. A primary care physician has been the first stop to diagnose & treat illness. Now, primary care is still where you go when you are sick & want to feel better, but also when you need help with the health care system & when you are well & want to get healthier.

Only you can improve your health, but you do not have to do it alone.  At CityLife, we know health is more than just physical, which is why we have a care team in place to take care of the whole you, as a person, and not as a condition! The minute you walk in the door, a warm family feel not only makes you feel cared for, but comfortable.  At CityLife, you not only have a doctor, but a whole team of health care professionals built around you and your needs!  The health care system is hard to navigate, and at CityLife, we know that. That is why we have made it our mission to make health easier by offering same-day visits, walk-in care and so much more!

Position Description: Reporting to the Medical Director, the Social Services Coordinator is responsible for the development and implementation of a psychosocial support program, while building and maintaining relationships with a multitude of outside community agencies and providers. The Social Services Coordinator will collaborate with a multidisciplinary care team to provide professional expertise and consultation, and work with members and their caretakers, to facilitate the coordination, and monitoring, of social services needed and utilized.

Essential Duties:

• Creates programming that supports utilization management and related service coordination for social and behavioral health dispositions.
• Engages in process improvement within the organization, and with community partners, to provide the best possible member outcomes.
• Provides leadership, guidance and daily supervision to community health workers.
• Establishes relationships with organizations, service providers, and community agencies.
• Works collaboratively with internal and external contacts to ensure member needs are met.
• Supports and monitors community-based referrals to members and their families to address identified concerns; this includes, but is not limited to, concrete resource connection, coordination of appointments and follow-up, and assisting in obtaining needed documentation.
• Educates community health workers and primary care team on opportunities for improving and understanding social determinants of health that impact overall health and treatment plan of members.
• Leads and promotes brief problem-solving cognitive interventions aimed at modifying negative thinking, promoting self-efficacy, and increasing health belief for appropriate members.
• Utilizes motivational interviewing and psycho-education with appropriate members and their support systems to mitigate risks for substance abuse, mental health disorders, chronic disease exacerbation and prevention strategies.
• Provides professional expertise and consultation to the primary care team.
• Maintains documentation in compliance with state, federal, professional and ethical guidelines.

Minimum Requirements:

• Bachelor’s degree in social work (BSW) from an accredited school
• At least 5-7 years of demonstrated experience in a similar role

Preferred Requirements:

• Licensed Clinical Social Worker (LCSW)
• Three (3) years’ experience working in a community-based organization
• Program development experience a plus
• Experience with leadership or mentorship is ideal