social worker

The Clinical Care Team will take referrals from primary care providers and will work with the primary care team to accomplish the following tasks:• Social support navigation for social determinants of health (SDOH) such as food insecurity, housing insecurity, etc.o Compile and maintain a resource list for SDOH resources including eligibility criteria, referral process, and contact informationo Collaborate with primary care nurse and providerso Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or providero Coordinate or make aware of social services resources, i.e., housing, clothing, food, mental health services, etc.o Collaborate with other social workers to identify patient and community resources• Conduct case management activitieso Work with hospitals for discharge planning, follow-up and educationo Assist with obtaining patient records from hospitalso Assist in securing needed medical equipment through community partnerso Conduct follow-up on care planso Identify patients lost to follow-up or overdue for care and assist them in returning to care• May assist with specialty referral navigationo Schedule, coordinate, and track non-BCS specialist and imaging referralso Assist with obtaining patient records from specialists and imaging centerso Compile and maintain resource list for specialty referrals including eligibility criteria, referral process, cost and contact information• Assist patients to locate and access low-cost prescription options such as patient assistance programs, discount retailers, etc.o May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companieso Assist patient with applications for programs such as CoverRx and RxOutreach• May help with other regional primary care-based initiatives with a social work component• Documents in patient's record, updates consults, and tags provider and/or clinical staff as necessary• Provide patient education or find appropriate education resourcesExpectations may include:Complete onboarding and orientationParticipate in regional office and primary care clinical meetings as requestedAttend provider meetings as requestedAttend Health Councils and other community meetings to build relationships with social service agencies and promote health department servicesIdentify barriers to care or assistance experienced by our patients and seek ways to address themTools and Equipment:1. Personal Computer2. Telephone3. Fax Machine4. Printer5. Scanner6. Copy Machine7. Calculator8. Personal Vehicle