Outreach Social Worker/ Coordinator

Boston Health Care for the Homeless Program; Boston (MA); On-site; USD 66,000 - 106,000; Full time

Benefits offered by this job

Sign-on bonus

Health, dental & vision insurance

403B retirement plan

Pre-tax MBTA pass

Job summary

Boston Health Care for the Homeless Program in Boston, MA seeks an Outreach Social Worker/Coordinator to lead weekly multidisciplinary HIV team outreach, engage highly vulnerable patients, and coordinate care across medical and behavioral health services.

This role emphasizes trauma-informed practice, motivational interviewing, harm reduction, and restorative justice approaches, with supervision of ARCH program activities and collaboration with community partners.

Qualifications

• Massachusetts LICSW and LMHC preferred; LCSW license required or eligible within specified timelines.
• Experience with trauma-informed care and motivational interviewing and harm reduction.
• Experience working in multidisciplinary health care teams.
• Bilingual English/Spanish preferred.

Responsibilities

• Conduct community-based outreach in homes, shelters, hospitals, and other settings.
• Provide trauma-informed social work and behavioral health interventions, crisis counseling, and safety planning.
• Support care coordination and discharge planning to ensure continuity of HIV care.
• Advocate and coordinate for patients involved with the criminal legal system and after release from incarceration.
• Provide motivational interviewing and harm reduction counseling.
• Develop and lead behavioral health groups for HIV team patients.
• Identify barriers to care and develop patient-centered engagement strategies.
• Collaborate with community agencies to ensure continuity of care.

Skills

Interpersonal skills

Communication

Organizational skills

Multidisciplinary teamwork

Crisis intervention

Bilingual English/Spanish

Education

LICSW

LMHC

LCSW license eligibility

Tools

Electronic Health Records

Job description

Who We Are

Since 1985, BHCHP’s mission has been to provide or assure access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. We care for over 11,000 homeless individuals each year and ensure that every one of these individuals can receive comprehensive health care, which includes primary care, behavioral health, medical respite, dental, case management, and more. Our staff work in 30+ locations across the city to serve some of our community's most vulnerable—and most resilient—citizens.

From our earliest days as a program, we have always sought to do work that is transformational: recognizing our shared humanity, centering trust, mutual respect, hope, and supporting the right of every individual to access the highest levels of health care and every staff member to reach their fullest potential. We continue to be committed to building bridges and breaking down physical and systemic barriers that our patients face and provide community-based health care services that are compassionate, dignified, and culturally appropriate.

Job Summary

NOW OFFERING A $4,000 SIGN ON BONUS

Hours: Full-time; 40 hours per week; Monday-Friday, 8:30am - 5:00pm

Union: None

Union Name: None

Patient Facing: Yes

We are looking to hire a HIV Team Outreach Social Worker/ Coordinator which is a unique position that integrates direct social work and behavioral health services, outreach coordination, program administration, and systems innovation within a multidisciplinary HIV Primary Care team. In this role, you will play a key role in developing and implementing restorative justice-informed approaches to patient engagement, staff support, and addressing challenging interactions within the care environment.

As the Outreach Social Worker/Coordinator, you will provide leadership and coordination for weekly multidisciplinary HIV team outreach activities, with the goal of supporting the team's most vulnerable patients in accessing and remaining engaged in comprehensive HIV care and behavioral health services, regardless of housing status or other barriers to care.

You will also work collaboratively with medical and behavioral health providers, nurses, case managers, and other outreach staff, as well as community partners and outside agencies, to strengthen continuity of care, promote therapeutic relationships, and address barriers to HIV care engagement.

Administrative and Leadership

• Provide leadership, coordination, and integration of weekly outreach activities within the HIV team and in collaboration with other BHCHP outreach teams, community partners, and outside agencies.
• Coordinate outreach activities with a focus on developing therapeutic relationships that promote engagement, retention, and continuity in HIV care.
• Screen referrals to the DPH-funded specialized linkage and retention program (“ARCH Program”), which provides high-intensity outreach-based case management and accompaniment services for up to 6-12 months for15–20 of the HIV team's most vulnerable patients who struggle to engage.
• Collaborate with the outreach team to establish appropriate goals and service plans for patients enrolled in ARCH.
• Provide quality assurance and oversight of DPH grant-funded ARCH activities and ensure completion of required documentation and reporting.
• Support planned transitions from ARCH to intensive medical case management when patients are determined by the multidisciplinary team to be ready for a less intensive level of outreach support.
• Provide direct supervision, consultation, and support to the ARCH Outreach Case Manager.
• Participate in weekly multidisciplinary patient care and monthly HIV team meetings.
• Facilitate weekly outreach planning meetings with team
• Attend weekly BHCHP Behavioral Health Team meetings.
• Participate in intra-agency committees and other organizational initiatives as requested.
• Complete grant reporting, program documentation, and other reports as required.
• Complete mandatory reporting in accordance with Massachusetts laws and regulations.
• Provide documentation for grants, quality improvement initiatives, and special projects as directed by the supervisor.

Direct Social Work and Outreach Services

• Conduct community-based outreach alongside other members of the outreach team in a variety of settings, including patients' homes, shelters, treatment programs, hospitals, day centers, and street-based settings.
• Provide trauma-informed social work and behavioral health interventions based on patient needs, including crisis counseling and connection to emergency psychiatric services when indicated, safety planning, grounding, emotion-regulation strategies, and behavioral de-escalation.
• Support care coordination and discharge planning for patients receiving inpatient care at local hospitals, with particular attention to continuity of HIV care following discharge.
• Provide advocacy and support care coordination for patients involved in the criminal legal system, including supporting reconnection to HIV and other health services following release from incarceration.
• Provide motivational interviewing and harm reduction counseling for patients with substance use disorders and others engaging in behaviors that may increase health risks.
• Develop and facilitate behavioral health groups for HIV team patients based on identified needs and interests.
• Work collaboratively with patients and the multidisciplinary team to identify barriers to care and develop practical, patient-centered strategies to support engagement and retention.
• Collaborate with community agencies and other service providers to facilitate continuity of care and access to the health and social services needed.

Restorative Justice and Team Support

• Support the HIV team in addressing difficult, disruptive, or harmful patient behaviors using restorative justice-informed approaches that promote accountability, repair, therapeutic relationships, and sustained engagement in care.
• Consult with team members regarding challenging patient interactions and assist in developing individualized approaches that balance patient needs, staff safety, and the therapeutic environment.
• Support the development of mutual care or behavioral agreements when appropriate.
• Facilitate restorative conversations and/or restorative justice circles when appropriate and in collaboration with patients and team members.
• Help the team identify opportunities to prevent escalation and strengthen relationships between patients, staff, and the broader care community.
• Support the HIV team in addressing grief, secondary trauma, and vicarious trauma associated with providing frontline care to a highly vulnerable patient population.
• Contribute to a culture of reflection, mutual support, accountability, and continuous learning within the HIV team.

Qualifications

Education and Experience

• Massachusetts LICSW and LMHC preferred, LCSW required or license eligible
• Must be licensed or must obtain license within 18 months (for LCSW) or 42 months (for LMHC) of hire date
• Demonstrated experience and interest in working with socially and medically vulnerable populations, including people experiencing homelessness, substance use disorders, mental health challenges, and involvement with the criminal legal system.
• Experience providing trauma-informed care and working within motivational interviewing and harm reduction frameworks.
• Experience working effectively within multidisciplinary health care teams.
• Experience providing services in non-traditional or community-based outreach settings preferred.
• Management or clinical supervision experience is preferred.
• Familiarity with restorative justice principles and practices is preferred.
• Experience working with people living with HIV and/or experience in HIV care is preferred.

Knowledge and Skills

• Strong interpersonal, communication, and relationship-building skills.
• Strong organizational, time-management, and coordination skills.
• Demonstrated ability to work effectively in complex multidisciplinary environments.
• Experience with behavioral de-escalation and crisis intervention.
• Ability to work independently in community-based settings while maintaining effective communication and collaboration with the broader care team.
• Computer proficiency and experience with electronic health records.
• Experience with quality improvement processes preferred.
• Bilingual English Spanish preferred.

Other Job Requirements

• Commitment to providing equitable, culturally responsive, trauma-informed, and patient-centered care.
• Demonstrated ability to work respectfully and effectively with diverse populations, including communities of color, LGBTQ+ communities, people with limited English proficiency, people with histories of incarceration, people who use substances, people experiencing behavioral health challenges, and people experiencing homelessness.
• Commitment to harm reduction, patient autonomy, and collaborative approaches to care.
• Ability to navigate complex clinical and social situations while maintaining appropriate professional boundaries and a focus on patient and staff safety.

Compensation and Benefits

NOW OFFERING A $4,000 SIGN ON BONUS

• The compensation increases based on years of experience and ranges from $66,000 - $105,600 annually. Additional compensation for LICSW and LMHC.

• BHCHP full-time employees are eligible for our competitive time off program, health, dental and vision insurance, 403B retirement savings plan,pre-tax MBTA pass program with 40% discount, additional compensation for demonstrated bilingual proficiency and more.Benefits are prorated for part-time employees.

As an equal opportunity employer, Boston Health Care for the Homeless Program is committed to providing employment opportunities to all qualified individuals and does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity and expression, sexual orientation, national origin, disability, age, marital status, veteran status, pregnancy, parental status, genetic information or characteristics, or any other basis prohibited by applicable law.

Covid-19 Vaccination: Proof of Covid-19 vaccination(s) is optional for employment. Candidates who are offered employment will be given details about how to demonstrate receipt of vaccination if they choose to.

Please Note: Employment at Boston Health Care for the Homeless is at-will. Boston Health Care for the Homeless does not sponsor work authorization visas.