Social Worker

Job Type

Full Time


Details: Commensurate with experience



Start Date


Application Deadline



New York
United States


Social Worker • New York, NY 

Social Workers report to the Chief Health Officer and their job function is to train, manage, and supervise a team of community health workers (Health Coaches) who provide self-management education, health coaching, and care coordination services to adults living with chronic diseases such as asthma, diabetes, hypertension, and congestive heart failure.Social Workers provide clinical social work services to clients and their families, including crisis intervention and assessment and treatment of emotional and behavior problems. Social Workers will coach clients on how to manage ongoing health conditions and provide therapy to help clients make positive behavior changes. Social Workers also support the care team in community outreach and engagement activities by screening clients for social determinants of health, depression, and anxiety. Social Workers must have strong interpersonal skills, knowledge of motivational interviewing, goal setting, and adult education principles. Social Workers will work closely with healthcare professionals to coordinate care needs across multiple medical and social providers. City Health Works seeks individuals who are well organized, flexible, goal oriented, committed to healthy living, and who enjoy motivating others to achieve to their goals.

Founded in 2013, City Health Works (www.cityhealthworks.comcreates healthier, stronger neighborhoods by providing health coaching and care coordination to individuals struggling with chronic illnesses. City Health Works currently operates in Harlem, NY and is gaining increasing recognition nationally for its role in building a high performing community health workforce that can improve health while reducing costs.


● Provide guidance, support, training, and supervision to Health Coaches on care coordination and case management

● Help identify and address social determinants of health for clients served through case management and referrals

● Provide client mental health assessments and develop comprehensive care plans for those struggling with chronic illnesses and co-morbid depression and anxiety

● Assist with development of depression care and risk assessment protocols

● Help create and manage crisis intervention plan for Health Coaches

● Provide direct counseling and support to City Health Works clients via individual counseling and support groups to help clients manage and cope with depression, anxiety, stress, and illness

● Conduct mental health and wellness trainings for Health Coaches

● Complete all appropriate documentation for each client on caseload

Clinic and community engagement, community outreach, and referral management

● Engage in collaborative care meetings with Primary Care team at partnering clinical practices to review progress towards recruitment goals and strategies and conduct reviews of complex patients

● Manage outreach at community sites

● Educate Health Coaches regarding community resources and referrals


● Attend leadership and organizational meetings, when relevant

● Ensure compliance with all organizational safety and privacy and compliance procedures. Communicate concerns or questions to the Privacy, Security, and/or Compliance Officer when necessary in a timely way

Work environment: 50% remote, 25% field (supervising and shadowing Health Coaches), 25% office-based (administrative, individual and group meetings)


● NYS License to practice clinical social work required

● Work authorization for employment in the U.S. is required.

● Requires Master’s degree of social work (MSW)

● 2-3 years Counseling experience required (particularly in the areas of depression, anxiety, stress, and managing the burden of chronic illness)

● 2-3 years Case Management or Care Coordination experience preferred

● Bilingual (English/Spanish) strongly preferred


Competitive Benefits Package (medical, dental, vision, 401K, Wage Works, etc.) through TriNet. Detailed benefits.

20 days total of Vacation, Personal Time Office, and Sick Time.

In addition, company-wide holiday between Christmas and New Year’s Day.

Level of Language Proficiency

Bilingual (English/Spanish) strongly preferred

Professional Level

None specified

Minimum Education Required

Master's degree

How To Apply


Send a Resume and Cover Letter with “Social Worker” in the subject line to: