Referrals and Outreach:

• Develop trust and rapport with clients and hospital staff in order to identify individuals who could benefit from social work support and transitional care coordination.
• Work with hospital staff to identify and engage clients and support hospital staff in making referrals to the CCIS team, as appropriate.
• When necessary, follow up with referral source(s) to learn more about the client being referred, reason for hospitalization and/or reason for referral, to support in development of Coordinated Care Plan (CCP).
• Develop relationships with other service providers in order to make seamless, effective referrals and service connections.
• Work closely with CCU central intake and program managers to identify clients with frequent hospital/ED use who may benefit from CCIS support to reduce unnecessary hospital use.

Direct Client Support:

• Conduct psychosocial, psychological, and geriatric assessments.
• Coordinate care through service navigation, planning, and short-term (up to 90 days) case management.
• Provide clinical and supportive counseling using diverse therapeutic approaches.
• Assess risk and deliver crisis intervention and action plans in urgent situations.
• Offer crisis support and practical help to clients and caregivers in homes or community settings
• Link clients to internal/external resources, programs, and services.
• Support hospital-to-community transitions and reduce ED visits and re-admissions.
• Arrange interpretation services and facilitate access to needed supports.
• Develop and lead onsite programs, support groups, and social activities.
• Collaborate with the CCIS team, manage referrals, and contribute to team development and service capacity planning.

General:

• Follow organizational policies and maintain accurate records, documentation, and data reporting
• Communicate effectively with on-site staff, supervisors, and community partners.
• Support student placements and volunteers through mentorship, training, or supervision.
• Stay informed about community services and participate in ongoing training, meetings, and supervision.
• Represent the team on committees and perform other duties as assigned.

What You Bring to the Team

• Minimum of 3 years related experience in mental health, addictions, and/or social work. Demonstrated experience facilitating psycho-social groups and supporting individuals with significant mental health and/or addictions issues, cognitive impairment (e.g. dementia), and chronic health issues from a harm reduction, trauma informed, and mental health recovery approach is required.
• Experience in conflict mediation, client engagement and community development is required.

What Will Set You Apart

• Skilled in supporting clients with complex mental health, addictions, geriatric, cognitive, trauma, and chronic health issues.
• Knowledgeable in addiction theories, evidence-based treatments, and therapeutic counseling approaches.
• Experienced in short-term case management, care coordination, assessments, and system navigation
• Strong in crisis intervention, de-escalation, conflict resolution, and collaboration with service providers.
• Effective communicator with strong organizational, time management, and documentation skills.
• Able to work independently and in teams, using sound judgment and a client-centered approach.

WoodGreen is an equal opportunity employer. We are committed to providing an inclusive and barrier-free selection process and work environment. If contacted in relation to an employment opportunity, please advise our People & Culture representatives at careers@woodgreen.org of the accommodation measures required. Information received relating to accommodation will be addressed confidentially.
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