| Job Description | 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. - 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:
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 |
