Patient Support Specialist - Social Worker

East Valley Community Health Center Inc.; Pomona (CA); On-site; USD 43,000 - 48,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Retirement plan

Paid time off

Job summary

East Valley Community Health Center Inc. seeks a Patient Support Specialist (PSS) Social Worker to address patients' behavioral health, substance use, and social needs through counseling, crisis interventions, and referrals.

The role includes field outreach, home visits, and coordinating with HIV testing and care teams to enroll patients into appropriate services. Required is a Master’s degree in social work or related field, plus 2+ years’ experience with vulnerable populations.

Qualifications

• Master’s degree in social work, counseling, psychology, or related field.
• At least two years of relevant work experience with patients in public health, community services, or medical settings.
• Experience conducting patient or client assessments.
• Experience working with vulnerable populations (e.g., addiction, mental illness, homelessness).
• Strong interpersonal skills; ability to advocate for patients; ethical, culturally competent care.

Responsibilities

• Assess patients' behavioral health, substance use, and social needs; provide counseling and referrals.
• Conduct individual, couple, and family counseling and psychotherapy sessions.
• Deliver crisis interventions and trauma-informed care; provide linkage to resources.
• Collaborate with clinic teams to ensure comprehensive support and care.
• Perform Social Determinants of Health assessments within five days of contact.
• Develop intervention plans and provide education to reduce risk and improve adherence.
• Complete documentation within 24 hours of service delivery.

Skills

Interpersonal skills

Advocacy

Cultural competence

Bilingual English/Spanish

Education

Master’s degree in social work, Counseling, Psychology, or a related field

Job description

Job Category: Social Services

Requisition Number: PSSSO001405

• Posted : August 12, 2026
• Full-Time
• On-site

Locations

Showing 1 location

Pomona, CA 91766, USA

Description

POSITION PURPOSE:

The Patient Support Specialist (PSS) Social Worker will play a crucial role within both the Patient Support Services (PSS) and Comprehensive Care Clinic teams. The primary objective of this position is to assess and address patients' behavioral health, substance use, and social needs through counseling, crisis interventions, and referrals, with the goal of improving overall health outcomes and supporting patients in achieving or maintaining their health goals. The position also supports patients in accessing resources related to housing, transportation, and other social determinants of health.

MAJOR POSITION RESPONSIBILITIES AND FUNCTIONS:

• Evaluate patients' needs for behavioral health services, substance use counseling, housing, and transportation, and make appropriate referrals and linkages.
• Conduct individual, couple, and family counseling and psychotherapy sessions.
• Deliver crisis interventions, offering immediate support in challenging situations.
• Provide support services using social determinants of health, harm-reduction, and trauma-informed care principles.
• Collaborate with PSS and other clinic team members, including the Behavioral Health team, to ensure patients receive comprehensive support and care.
• Stay informed about local, state, and federal services available to patients.
• Address patients’ socioeconomic needs, assist with referrals, linkages, monitoring, and tracking outcomes as part of the PSS team.
• Serves as liaison between HIV counseling and testing team and medical clinic, ensuring new patients are enrolled in care smoothly and promptly.
• Perform home visits and other field outreach as needed on a case‑by‑case basis.
• Conduct a comprehensive Social Determinants of Health assessment through a cooperative, interactive face‑to‑face interview within five working days of patient contact, considering age, gender, cultural, and linguistic factors. The assessment will gather information on the client's social, emotional, behavioral, mental, spiritual, and environmental status, as well as family support systems, coping strategies, strengths, weaknesses, and adjustment to illness.
• Develop an intervention plan within five days, incorporating information from the Social Determinants of Health assessment and considering the patient’s behavioral, psychological, developmental, and physiological strengths and limitations.
• Provide patient counseling and intervention sessions, including targeted educational interventions that focus on risk reduction strategies. Additionally, offer support for behavioral health referrals as needed, with the goal of preventing high‑risk behaviors and enhancing patient adherence.
• Offer periodic training to clinic staff.
• Provide services to patients who are not yet enrolled in PSS or clinic‑based programs.
• Provide guidance and direction to the ROS/HS to ensure timely follow‑up with patients and accurate completion of documentation.
• Attend meetings and training sessions to enhance skills and stay current on nursing best practices and other related issues. Ensure compliance with continuing education requirements.
• Participate in Quality Improvement (QI) meetings, presentations, and other required QI activities. Monitor and analyze trends related to non‑medical quality improvement (QI) indicators, such as the effectiveness of risk reduction interventions.
• Document patient interactions and progress and contributes to program evaluation.
• Actively participates in case conferences.
• Complete all patient documentation within 24 hours of service delivery.
• Adhere to HIPAA guidelines regarding patient care and confidentiality.
• Perform additional duties as assigned by the supervisor, as needed to support departmental goals and operations.

POSITION REQUIREMENTS AND QUALIFICATIONS:

• Master’s degree in social work, Counseling, Psychology, or a related field from an accredited program.
• At least two years of relevant work experience with patients in public health, community services, or medical settings.
• Experience conducting patient or client assessments.
• Experience working with vulnerable populations (e.g., individuals with addiction disorders, mental illness, homelessness, or those who inject drugs).
• Strong interpersonal skills.
• Ability to advocate for patients effectively.
• Ability to deliver care in an ethical, non‑judgmental, culturally competent, and non‑discriminatory manner.
• Willingness and ability to learn how to navigate the complex housing support systems within Los Angeles County.
• Comfortable performing field-based work when necessary.

KNOWLEDGE:

• Knowledge of HIV, behaviors that transmit HIV, and co‑morbid disease conditions associated with HIV.

LANGUAGE SKILLS:

• Fluent in both English and Spanish preferred.

LICENSES & TRANSPORTATION:

• Valid Class C California Driver’s License, proof of vehicle insurance, and reliable transportation to travel throughout Los Angeles County.

CULTURAL COMPENTENCE:

• Ability to work effectively with individuals from diverse races, ethnicities, nationalities, sexual orientations, gender identities, gender expressions, socio‑economic backgrounds, religions, ages, English‑speaking abilities, immigration statuses, and physical abilities in a multicultural environment.

WORKING CONDITIONS/PHYSICAL/MENTAL ABILITIES AND PROCESS:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions.

• Work requires long periods of sitting, turning, twisting, reaching, speaking, hearing, seeing and the ability to articulate clearly, use of hands to finger, reaching with hands and arms.
• Ability to stand, sit, stoop, kneel, and bend to speak to patients.
• Ability to write notes, treatment plans, track records and reports.
• Ability to work productively in a small office space used by multiple employees.
• Travel to and from clinic or meeting sites within geographic service area.

DOE: $31.00 - $34.54 HR

East Valley offers a competitive salary, and excellent benefits including medical, dental, vision, and defined contribution retirement plan. You will also enjoy a work‑life balance with paid time off and paid holidays throughout the year.

EOE is the Law. It is the stated policy of EVCHC to conform to all the laws, statutes, and regulations concerning equal employment opportunities and affirmative action. We strongly encourage women, minorities, individuals with disabilities, and veterans to apply to all of our job openings. We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity, or national origin, age, disability status, Genetic Information & Testing, Family & Medical Leave, protected veteran status, or any other characteristic protected by law. We prohibit Retaliation against individuals who bring forth any complaint, orally or in writing, to the employer or the government, or against any individuals who assist or participate in the investigation of any complaint or otherwise oppose discrimination.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.