Social Worker

POST DATE:  November 15  2019


RESPONSIBLE TO: Program Director, Community Health Home

COMMITMENT (HOURS): Full-time (40 hours/week)

STATUS:  NonExempt (3 months orientation period)


Family Bridges in Oakland is looking for a full-time Social Worker to join our Community Health Home (CHH) program. CHH is a Community Based Care Management Entity (CB-CME) serving Medi-Cal members of Alameda Alliance for Health and Anthem Blue Cross under their Alameda County Care Connect/Whole Person Care and Health Homes programs. The successful candidate thrives in a positive, team-driven environment, and enjoys working with frail older adults; persons with complex chronic medical conditions, disabilities or special needs; and/or people facing houselessness, substance abuse, mental health issues. We are looking for a trusted member of the community to: facilitate access to services and resources (housing, transportation, healthcare, social services); stabilize and ensure clients achieve a safe, stable and healthy living environment; and enhance the quality and cultural competence of client services.


The Social Worker provides mental health services through helping the most vulnerable members of our community discover options to a wide range of social determinants toward their health and well-being. The Social Worker will serve as an integral team member and is responsible for performing psychosocial/ comprehensive risk assessments, developing and implementing client-centered care plans, and facilitating communication between the client, family, social supports, and other providers and services. Interactions with clients will be performed onsite at Family Bridges and/or in clients’ current place of residence (including hospitals, skilled nursing or other care facilities, houseless residence or encampments, and temporary or transitional housing).


  • Provide case management, crisis intervention and support to clients
  • Support clients in identifying their needs, setting goals, and developing structured plan for achieving those goals
  • Meet clients and other service providers in various settings, such as at place of residence (including hospitals, skilled nursing or other care facilities, houseless residence or encampments, and temporary or transitional housing), and public benefits and other community based settings
  • Help clients connect with appropriate social services and support
  • Develop relationships with local social service organizations and agencies, and agency’s partners
  • Provide advocacy for clients in non-legal settings (i.e., local housing authorities, social service offices, community-based organizations)
  • Serve as an interdisciplinary team (IDT) member responsible for developing and implementing a comprehensive, integrated plan of care, monitor progress toward objectives by evaluating behavioral adjustments and communicates client changes to team members
  • Complete assessments and care plan updates for all clients while continually evaluating social service needs of the clients and their families
  • Make referrals to community resources including those necessary for housing, financial management, benefit eligibility and to address related client needs
  • Manage an assigned caseload; document encounters with clients and correspondence regarding clients’ care management, and prepare narrative and other reports
  • Develop and maintain working relationships with other agencies, such as Department of Social Services, psychiatric facilities, hospitals, social agencies, housing services, community health clinics, other community partners, and participate in hospital and/or SNF discharge planning
  • Maintain the confidentiality of all company procedures, results and information about clients, clients or families in conformance with HIPAA principles
  • Participate in programmatic meetings, trainings, and collaborations, including but not limited to preparing and presenting cases during care conferences, as well as contributing to discussions, goal setting and outcomes, and problem solving
  • Complete administrative tasks, such as those related to reporting, and client case management
  • Engage in professional development to enhance client services and student supervision, as applicable
  • Perform additional tasks as assigned by Supervisor


  • Bachelors’ degree in Social Work from an accredited school of social work
  • Minimum of one year experience working with diverse range of groups, including frail older adults, people of color, the unhoused, immigrants, non-English speakers, people with serious mental illness or suffering from substance use, persons with complex chronic medical conditions or special needs, formerly incarcerated people, service providers, government employees, and community partners
  • Experience working in a community outreach program performing duties such as intake, peer counseling, assessments, program screening, placement and referral
  • Experience integrating motivational interviewing and/or trauma informed care practices.
  • Work experience in community based health care service capacity
  • Excellent oral and written communication skills in English
  • Aptitude to work under pressure in an empathetic and professional manner
  • Strong interpersonal skills, flexibility, and demonstrated ability to work well independently and as part of a team
  • Ability to handle multiple tasks
  • Valid California driver’s license
  • Up-to-date medical physical examination and immunizations


  • Masters’ degree in Social Work
  • Work experience with providers and community resources in Oakland, CA or Alameda County
  • Familiarity with Alameda County Care Connect/Whole Person Care and Health Home programs, HMIS/Coordinated Entry System, and/or Community Health Record System
  • Bilingual English and Cantonese, Mandarin, or Vietnamese a plus
  • Experience using a Salesforce database/CRM platform


  • Ability to communicate clearly with others
  • Ability to see and hear in order to interact with others
  • Ability to use a computer as well as a smartphone and/or tablet (e.g. iPad)
  • Ability to travel locally and perform responsibilities in various environments multiple times a day
  • To lift a minimum of 20 lbs
  • Vision 20/20 with correction

SALARY RANGE:  Salary depending on qualifications and experience, plus benefits.

TO APPLY: Send, fax or e-mail resume to: Human Resources, Family Bridges, Inc., 168 – 11th Street, Oakland,   CA 94607,  Fax: (510)839-2435 or E-mail to: [email protected]

Family Bridges, Inc. is a non-profit multi-services community based organization that has been serving the Asian American communities in the East Bay for more than 50 years.  Family Bridges, Inc. is an equal opportunity employer regardless of race, color, religion, sex, national origin, marital status, sexual orientation, age or disability.