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 such as food insecurity, housing insecurity, etc.

o Compile and maintain a resource list for 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

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

Job Type: Contract

Pay: $26.16 - $27.85 per hour

Experience:

• Group therapy: 1 year (Required)
• Care plans: 1 year (Required)
• Discharge planning: 1 year (Required)

Ability to Commute:

• Cookeville, TN 38501 (Required)

Ability to Relocate:

• Cookeville, TN 38501: Relocate before starting work (Required)

Work Location: In person