Social Worker

Responsibilities

• Take referrals from primary care providers and work with the primary care team to accomplish tasks.
• Navigate 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.
• Identify patient and community resources and collaborate with other social workers.
• Conduct case management activities.
• Work with hospitals for discharge planning, follow-up, and education.
• Aid in obtaining patient records from hospitals.
• Aid in securing needed medical equipment through community partners.
• Follow up on care plans.
• Identify patients lost to follow-up or overdue for care and assist them in returning to care.
• Assist with specialty referral navigation.
• Schedule, coordinate, and track non-BCS specialist and imaging referrals.
• Aid in 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.
• Assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies.
• Aid patients with applications for programs such as CoverRx and RxOutreach.
• Help with other regional primary care-based initiatives with a social work component.
• Document in patient’s record, updates consults, and tag provider and/or clinical staff as necessary.
• Provide patient education or find appropriate education resources.

Qualifications

• Bachelor’s degree in Social Work or related field.
• Current license to practice as a Social Worker in the state of Tennessee.
• Experience working with clients facing social determinants of health issues.
• Strong communication and collaboration skills.
• Ability to work independently and as part of a team.
• Proficiency in Microsoft Office Suite.