Social Worker 2

Job Description

Job Description

Description

Job Duties :

The Clinical Care Team will take referrals from primarycare providers and will work with the primary care team to accomplish thefollowing tasks :

Social support navigation for social determinants ofhealth (SDOH) such as food insecurity, housing insecurity, etc.

Compile and maintain a resource list for SDOH resourcesincluding eligibility criteria, referral process, and contact information

Collaborate with primary care nurse and providers

Provide in-person or remote social needsscreening / 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 patientand community resources

Conduct case management activities

Work with hospitals for discharge planning, follow-up andeducation

Assist with obtaining patient records from hospitals

Assist in securing needed medical equipment throughcommunity parers

Conduct follow-up on care plans

Identify patients lost to follow-up or overdue for careand assist them in returning to care

May assist with specialty referral navigation

Schedule, coordinate, and track non-BCS specialist andimaging referrals

Assist with obtaining patient records from specialistsand imaging centers

Compile and maintain resource list for specialtyreferrals including eligibility criteria, referral process, cost and contactinformation

Assist patients to locate and access low-costprescription options such as patient assistance programs, discount retailers,etc.

May assist with patient assistance program applicationsand serve as a patient-provider liaison with the drug companies

Assist patient with applications for programs such asCoverRx and RxOutreach

May help with other regional primary care-basedinitiatives with a social work component

Documents in patients record, updates consults, and tagsprovider and / or clinical staff as necessary

Provide patient education or find appropriate educationresources

Expectations may include :

Complete onboarding and orientation

Participate in regional office and primary care clinicalmeetings as requested

Attend provider meetings as requested

Attend Health Councils and other community meetings tobuild relationships with social service agencies and promote health departmentservices

Identify barriers to care or assistance experienced byour patients and seek ways to address them

Tools and Equipment :

Personal Computer

Telephone

Fax Machine

Printer

Scanner

Copy Machine

Calculator

Personal Vehicle

Other office related equipment as required