Social Worker

Compile and maintain a resource list for department 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 speciality referral navigation.

Tools and Equipment:

• Personal Computer
• Telephone
• Fax Machine
• Printer
• Scanner
• Copy Machine
• Calculator
• Personal Vehicle