Social Worker 2: Community Care Navigator (SDOH)

Nleague Services Inc.; Elizabethton (TN); On-site; USD 45,000 - 65,000; Full time

Job summary

Social Worker 2 position with TN DOH based in Elizabethton, TN. Onsite role working 8:00 AM to 4:30 PM for 6+ months, serving patients through the Clinical Care Team and coordinating social determinants of health resources.

Responsibilities include referrals from primary care, SDOH navigation, case management, discharge planning, and collaboration with providers to support patient access to housing, food, and medical services. Onsite equipment and field travel as needed.

Responsibilities

• 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

Job description

Social Worker 2 position with TN DOH based in Elizabethton, TN. Onsite role working 8:00 AM to 4:30 PM for 6+ months, serving patients through the Clinical Care Team and coordinating social determinants of health resources.

Responsibilities include referrals from primary care, SDOH navigation, case management, discharge planning, and collaboration with providers to support patient access to housing, food, and medical services. Onsite equipment and field travel as needed.