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Oregon Health & Science University Clinical Outreach Social Worker, HIV linkage to Care Coordination - Limited Duration in Portland, Oregon

The Clinical Outreach Social Worker (COSW) provides compassionate interventions to patients with complex psycho-social needs who have discharged from the OHSU Emergency Department or inpatient hospitalization. COSWs possess advanced clinical skills and expertise in navigating complex healthcare systems. The COSW prioritizes clients with limited connections to outpatient services and frequent utilization of emergency or inpatient care. This work requires a unique skill set, flexibility, and the ability to coordinate with a vast network of community partners to offer effective care. Job responsibilities include screening patients to identify those who may benefit from enrollment in the program, conducting comprehensive needs assessments, and identifying appropriate community referral resources. The COSW engages patients via intensive outreach efforts, including both in person and telephonic contacts. Assessments and interventions occur in a variety of setting including in the hospital, on the streets, in homes, at clinics, and in other community settings. The COSW coordinates treatment efforts with other OHSU departments, community partners and affiliates to advocate for the needs of patients. Interventions aim to reduce unnecessary hospital and emergency visits by improving access to medical care, addictions treatment, mental health services and housing. While assisting clients to access services, the COSW identifies client strengths, models problem-solving skills, encourages mutual participation, and enhances self-advocacy abilities. The COSW participates in data collection for program evaluation purposes and partners with other team members to ensure effective implementation of services. The COSW demonstrates values and care delivery consistent with the NASW code of ethics.

Specialty Addendum: HIV Linkage to Care Coordination: this position will initiate contact with recently diagnosed/out of care patients and link them with HIV treatment and resources. This position will provide patients with basic disease education and connection to County services as appropriate for partner notification. This position will serve as an expert in HIV-specific resources, both within OHSU and in the broader community. This position will be shared with Partnership Project’s HIV Case Management program and have a connection to the full continuum of HIV Care in the Portland metro area.

Key Responsibilities & Performance Standards:

This position conducts comprehensive clinical assessments of patients and their families/support systems, with particular attention to social determinants of health, coping with life-changing diagnoses, mental health stability and safety, substance use, and risk of abuse, neglect, or exploitation. Assessments may occur in the ED, an inpatient unit, a clinic, a community location, or the patient’s home.

This position will provide outreach to patients who are newly diagnosed with HIV after receiving a test at the OHSU ED. This position will make contact with the patient and inform them of their test results through telephonic or in person outreach visits in accordance with safety guidelines. This position will provide patients with individual behavioral risk reduction counseling and HIV education, as well as a variety of other intensive case management services as needed. Services include assisting patients in stabilizing housing, accessing financial entitlements, identifying primary medical care, seeking mental health and substance use disorder treatment, building interpersonal communication and system navigation skills, establishing supportive community connections, implementing support groups and facilitating cross-site communication and care coordination between OHSU, other healthcare organizations and community agencies. This position will coordinate with appropriate county Disease Intervention Specialists to avoid duplication of effort. This position will refer to HIV-specific Medical Case Management services through OHSU Partnership Project, Multnomah County HIV Health Services, Kaiser Immune Deficiency Clinic, or others as appropriate based on patients’ preferences and resources.

This position will assist in the creation of forms, documents, and spreadsheets as needed. This position will utilize existing databases and electronic medical record systems to access and input information relevant to patients’ medical care in accordance with HIPAA and all other applicable privacy laws and statutes. This position will be responsible for releasing all negative results through the OHSU Patient Portal system. This position will be expected to track relevant program data including diagnosis and linkage outcomes, as well as assist in the analysis and presentation of said data.

Participates in department meetings, Partnership Project staff meetings, HIV Case Management monthly meetings, as well as relevant workshops, seminars and training sessions to maintain professional competency. Participates in patient rounds as appropriate. Assists in staff education. Visits community facilities, programs, or services to acquire pertinent resource information. Receives monthly supervision from Partnership Project Director.

  • Master of Social Work or Bachelor of Nursing or other combination of education, experience and training in healthcare discipline that provided the opportunity to manage care coordination for various patient populations.

  • 3+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings. Experience working within the Portland social service community and extensive knowledge of community resources.

  • Experience working with an under-served adult population experiencing mental illness, substance abuse and chronic illness. Strong communication (written and verbal) and organizational skills; works well as part of an interdisciplinary team, is pro-active, flexible and is a solution-focused problem-solver.

  • Oregon LCSW or Oregon RN

  • Valid OR/WA driver’s license with an acceptable driving history and access to a car on a daily basis for home visits

  • National Association of Social Workers Code of Ethics

  • Oregon Board of Clinical Social Workers

  • Regular and consistent attendance at work.

  • 5+ years of professional experience diagnosing, treating and advocating for adults with mental illness and co-occurring substance abuse disorders in medical or community mental health settings. Experience working within the Portland social service community and extensive knowledge of community resources. Experience conducting home visits and community outreach.

  • Bilingual/bicultural Spanish-speaking preferred

  • Oregon LCSW; Board-certified to provide clinical supervision

This is a limited-duration, grant-funded position with funding secured through 3/31/2021. Plans are in place to apply for additional funding to extend this position beyond that date; however, there is no guarantee this will be successful.

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or

Recruitment ID: 2020-6031

External Company URL: dturner

Street: Marquam Hill

Job Type: AFSCME union represented

Posting Department: Care Transitions for the Underserved

Posting Pay: $71,080 - $107,635 DOE

Posting FTE: 1.00

Posting Schedule: 1.0, Full time

Posting Hours: 8:00 am to 4:30 pm

HR Mission: Healthcare

Drug Testable: Yes