Service Linkage Worker

About Avenue360 Health and Wellness Avenue 360 is a FQHC that strives to provide high quality and caring service to promote healthy people and communities. Our 360-degree approach addresses medical needs and social and environmental challenges, like housing. Our compassionate care extends to those with and without insurance. We believe income must not determine the level of access to quality health care. Providing comprehensive, high quality, and caring service is the core of what we do, whether medical, hospice care, engaging adult activities, and supportive housing programs. We strive to address the many social determinants of healthy living in Greater Houston. Our Values PACT We take PRIDE in our work. We have a positive ATTITUDE. We are CURIOUS. We are COMMITTED. We are CARING and CUSTOMER-SERVICE oriented. We are a TEAM. We LEARN, GROW, and INNOVATE Overview: The Case Manager is a non-medical case management position on Avenue 360’s Social Services team and provides information, referrals, and assistance with linkage to Social Drivers of Health (SDOH) needs such as medical, mental health, substance abuse, housing, housing financial assistance, food, etc. for People Living With HIV (PLWH). This position is also responsible for client advocacy to decrease service gaps and remove barriers to services by assisting clients to develop and utilize independent living skills and strategies. Duties and Responsibilities: Provides information on the range of services offered by the social services team to clients and, if appropriate, his/her personal support team. Conducts brief RWGA-approved assessments on clients within five (5) working days of intake and performs reassessments, at minimum, at six (6) month intervals. Conducts comprehensive assessments for clients with mental health, substance abuse, and housing issues. Refer clients with comprehensive assessments to a Medical Case Manager for assistance. Facilitates linkages to resources that address transportation barriers (ride sharing, bus cards, etc.), housing stability issues (financial assistance in the form of rent payments through Avenue 360), food insecurity, medical, etc. Communicates with others (internally and externally) to provide, exchange, or verify information, answer questions, and address issues of clients. Documents services provided in client records, the Centralized Patient Care Data Management System (CPCDMS) database, and other database systems as instructed. Ensures data is entered into database systems within prescribed timeframes to satisfy requirements for chart closure and service billing requirements. Compiles and analyzes data for weekly, monthly, quarterly, and annual reports as scheduled or as requested. Participates in, at minimum, four (4) hours of individual and group clinical supervision activities each month. Attends at least one (1) Joint Prevention and Care Coordination meeting each year. Keeps abreast of new knowledge and techniques related to the practice of social work and new medical treatment modalities. Maintains knowledge of internal and external service-related resources. Performs other duties as ass