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
· Documents in patient’s record, updates consults, and tags provider and/or clinical staff as necessary
· Provide patient education or find appropriate education resources
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