Hybrid Social Care Navigator & Resource Specialist

nLeague; Altamont (TN); Hybrid; USD 48,000 - 68,000; Full time

Job summary

TN Department of Health is seeking a Social Worker 2 in Altamont, TN, for a hybrid role with a 12+ month duration. You will partner with primary care teams to navigate SDOH, assemble resource lists, and coordinate social services, referrals, and discharge planning.

You will conduct screenings, support case management, and assist in obtaining patient records and medications, enhancing access to care and community resources.

Responsibilities

• Social support navigation for social determinants of health (SDOH) such as food insecurity and housing insecurity.
• Compile and maintain a resource list for SDOH resources with eligibility criteria, referral processes, and contact information.
• Collaborate with the primary care nurse and providers to coordinate care.
• Provide in-person or remote social needs screening and assessment for primary care patients.
• Coordinate or refer to social services resources including 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 and identify patients lost to follow-up.
• Assist with specialty referral navigation and scheduling non-BCS referrals.
• Assist patients with obtaining records from specialists and imaging centers.
• Compile resource lists for specialty referrals, including eligibility, referral process, cost, and contact information.
• Assist patients in locating low-cost prescription options and patient assistance programs.
• Support applications for patient assistance programs and act as liaison with drug companies.
• Assist with applications for programs such as CoverRx and RxOutreach.
• Support regional primary care initiatives with a social work component.

Job description

TN Department of Health is seeking a Social Worker 2 in Altamont, TN, for a hybrid role with a 12+ month duration. You will partner with primary care teams to navigate SDOH, assemble resource lists, and coordinate social services, referrals, and discharge planning.

You will conduct screenings, support case management, and assist in obtaining patient records and medications, enhancing access to care and community resources.