Job Title

Job Duties: 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 information o Collaborate with primary care nurse and providers o Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider o 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 activities o Work with hospitals for discharge planning, follow-up and education o ssist with obtaining patient records from hospitals o ssist in securing needed medical equipment through community partners o Conduct follow-up on care plans o Identify patients lost to follow-up or overdue for care and assist them in returning to care • May assist with specialty referral navigation o Schedule, coordinate, and track non-BCS specialist and imaging referrals o ssist with obtaining patient records from specialists and imaging centers o Compile and maintain resource list for specialty referrals including eligibility criteria, referral process, cost and contact information • ssist 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 companies o ssist 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 • ttend provider meetings as requested • ttend 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: 1. Personal Computer 2. Telephone 3. Fax Machine 4. Printer 5. Scanner 6. Copy Machine 7. Calculator 8. Personal Vehicle Other office related equipment as required