Social Worker 2
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.
- Compile and maintain a resource list for SDOH resources including eligibility criteria, referral process, and contact information
- Collaborate with primary care nurse and providers.
- Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider.
- Coordinate or make aware of social services resources, i.e., housing, clothing, food, mental health services, etc.
- Collaborate with other social workers to identify patient and community resources.
- Conduct case management activities.
- Work with hospitals for discharge planning, follow-up and education.
- Assist with obtaining patient records from hospitals.
- Assist in securing needed medical equipment through community partners.
- Conduct follow-up on care plans.
- Identify patients lost to follow-up or overdue for care and assist them in returning to care.
- May assist with specialty referral navigation.
- Schedule, coordinate, and track non-BCS specialist and imaging referrals.
- Assist with obtaining patient records from specialists and imaging centers.
- 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.
- May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies.
- 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 resources.
Expectations may include:
- Complete onboarding and orientation
- Participate in regional office and primary care clinical meetings as requested
- Attend provider meetings as requested
- Attend Health Councils and other community meetings to build relationships with social service agencies and promote health department services
- Identify barriers to care or assistance experienced by our patients and seek ways to address them
Tools and Equipment:
- Personal Computer
- Telephone
- Fax Machine
- Printer
- Scanner
- Copy Machine
- Calculator
- Personal Vehicle