Social Worker

<strong>Duration: 11 Months</strong><br><br><strong>Social Worker </strong><br><br><strong>Job Duties:</strong><br><br>The Clinical Care Team will take referrals from primary care providers and will work with the primary care team to accomplish the following tasks:<br>&bull; Social support navigation for social determinants of health (SDOH) such as food insecurity, housing insecurity, etc.<br><br>o Compile and maintain a resource list for SDOH resources including eligibility criteria, referral process, and contact information<br><br>o Collaborate with primary care nurse and providers<br><br>o Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider<br><br>o Coordinate or make aware of social services resources, i.e., housing, clothing, food, mental health services, etc.<br><br>o Collaborate with other social workers to identify patient and community resources. Conduct case management activities<br><br>o Work with hospitals for discharge planning, follow-up and education<br><br>o Assist with obtaining patient records from hospitals<br><br>o Assist in securing needed medical equipment through community partners<br><br>o Conduct follow-up on care plans<br><br>o Identify patients lost to follow-up or overdue for care and assist them in returning to care. May assist with specialty referral navigation<br><br>o Schedule, coordinate, and track non-BCS specialist and imaging referrals<br><br>o Assist with obtaining patient records from specialists and imaging centers<br><br>o 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.<br><br>o May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies<br><br>o 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<br><br><strong>Expectations may include:</strong><br><ul><li>Complete onboarding and orientation</li><li>Participate in regional office and primary care clinical meetings as requested</li><li>Attend provider meetings as requested</li><li>Attend Health Councils and other community meetings to build relationships with social service agencies and promote health department services</li><li>Identify barriers to care or assistance experienced by our patients and seek ways to address them</li></ul>