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Duration: 10 Months

Locations: Gallatin, Clarksville, Murfreesboro (Tennessee)

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