Medical Social Worker

Location: Green Bay, Wisconsin

About the role

The Medical Social Worker provides timely assessment of urgent or unmet needs and care coordination services to patients in an outpatient setting. This role supports medical providers throughout the organization by identifying and addressing social determinants of health (SDOH) that impact patient well-being and access to care. The Medical Social Worker collaborates with interdisciplinary care teams to develop and implement patient-centered care plans, connects patients to community resources, and supports improved health outcomes and care continuity. This position supports multiple clinic locations to ensure consistent service delivery and patient support.

Responsibilities

• Develop, implement, monitor, and educate patients and families on individualized care plans in collaboration with interdisciplinary care teams to support patient-centered outcomes.
• Coordinate care across healthcare settings, advocate for access, and facilitate referrals to internal and external services (e.g., housing, transportation, food, financial assistance, behavioral health) ensuring continuity of care and appropriate follow-up.
• Provide solution-focused interventions, case management, and support to patients and families, promoting coping strategies and overall well-being.
• Document patient interactions, care coordination activities, and outcomes in the electronic health record.
• Conduct brief assessments of patient and caregiver needs to identify safety concerns, barriers to care, and social determinants of health impacting outcomes.

Qualifications

Education

• Bachelor's Degree in Social Work Required
• Master's Degree in Social Work Preferred

Experience

• 1-3 years of experience in healthcare, care coordination, or community-based work Preferred
• Experience working with diverse populations and addressing social determinants of health Preferred

Skills and Abilities

• Knowledge of medical social work practices, care coordination models, and the impact of social determinants of health on patient outcomes.
• Knowledge of community resources, public assistance programs, and healthcare delivery systems.
• Maintain knowledge of community resources and best practices in care coordination.