Social Worker 2

Job Duties: Hybrid 8:00 AM 4:30 PM Regular Shift

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
Personal Computer

Telephone

Fax Machine

Printer

Scanner

Copy Machine

Calculator

Personal Vehicle

Desired Skills and Experience

SOCIAL WORKER, SOCIAL SERVICE, PUBLIC HEALTH, VOLUNTEER