Clinical Social Worker

STI; Jackson (TN); On-site; USD 40,000 - 65,000; Full time

Job summary

STI's Clinical Care Team in Jackson, TN seeks a social care coordinator to support patients through social determinants of health, coordinate resources, and collaborate with primary care teams to ensure seamless care transitions.

Responsibilities include building SDOH resource lists, conducting screenings, coordinating referrals to housing, food, mental health, and patient assistance programs, and following up to re-engage patients.

Responsibilities

• Social support navigation for SDOH such as food and housing insecurity.
• Compile and maintain a resource list with eligibility criteria and contact information.
• Collaborate with the primary care nurse and providers.
• Provide in-person or remote social needs screening/assessment for referred patients.
• Coordinate or refer to housing, clothing, food, and mental health services.
• 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 and re-engage patients.
• May assist with specialty referral navigation and with non-BCS referrals and imaging.
• Assist patients with applications for programs like CoverRx and RxOutreach.
• Document in patient records and educate patients; liaison with providers as needed.

Job description

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 for care and assist them in returning to care
• May assist with specialty referral navigation
• Schedule, coordinate, and track non-BCS specialist and imaging referrals
• Assist with obtaining patient records from specialists and imaging centers
• 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.
• May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies
• 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
• Other office related equipment as required