Demo

Social Worker :: Jackson, TN

Software Technology Inc
Jackson, MS Full Time
POSTED ON 4/14/2025
AVAILABLE BEFORE 6/10/2025
Description:
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
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:
1. Personal Computer

2. Telephone

3. Fax Machine

4. Printer

5. Scanner

6. Copy Machine

7. Calculator

8. Personal Vehicle

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