Social Worker/Case Manager

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    Assist with obtaining patient records from hospitals

o    Assist 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    Assist 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

·         Assist 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    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