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

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