Clinical Social Worker — Care Coordination & Resources

STI; Jackson (TN); On-site; USD 55,000 - 75,000; Full time

Job summary

STI in Jackson, TN is seeking a Social Care Team member to support referrals from primary care and work with the care team to address social determinants of health. You will compile resources, screen patients for social needs, coordinate services (housing, food, mental health), and assist with discharge planning and record sharing.

Responsibilities include case management, collaboration with hospitals and community partners, and ongoing follow-up to reconnect patients to care.

Qualifications

• Social determinants of health navigation.
• Screening/assessment for social needs in primary care patients.
• Collaboration with care team and community partners.

Responsibilities

• 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 (housing, clothing, food, mental health, etc).
• Coordinate 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 returning to care.
• May assist with specialty referral navigation.
• Schedule, coordinate, and track non-BCS referrals.
• Assist with obtaining patient records from specialists and imaging centers.
• 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 and discount retailers.
• May assist with patient assistance program applications and liaise with 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.
• Document in patient’s record, update consults, and tag provider/clinical staff as necessary.
• Provide patient education or find appropriate education resources.

Job description

STI in Jackson, TN is seeking a Social Care Team member to support referrals from primary care and work with the care team to address social determinants of health. You will compile resources, screen patients for social needs, coordinate services (housing, food, mental health), and assist with discharge planning and record sharing.

Responsibilities include case management, collaboration with hospitals and community partners, and ongoing follow-up to reconnect patients to care.