Social Worker / Case Manager

Location: 1365 Main Street Altamont, Tennessee 37301 (Hybrid Job)
Duration: 12+ Months

About the Role

The Clinical Care Team will take referrals from primary care providers and work with the primary care team to address social determinants of health (SDOH) and related patient needs.

Responsibilities

• Provide social support navigation for social determinants of health (SDOH) such as food insecurity, housing insecurity, and other needs.
• Compile and maintain a resource list for SDOH resources, including eligibility criteria, referral process, and contact information.
• Collaborate with primary care nurses and providers.
• Conduct in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider.
• Coordinate or make patients aware of social services resources (e.g., housing, clothing, food, mental health services).
• Collaborate with other social workers to identify patient and community resources.
• Conduct case management activities, including hospital discharge planning, follow-up, and education.
• Assist with obtaining patient records from hospitals and specialists.
• Secure needed medical equipment through community partners.
• Conduct follow-up on care plans and identify patients lost to follow-up or overdue for care.
• Assist with specialty referral navigation, including scheduling, coordinating, and tracking non-BCS specialist and imaging referrals.
• Compile and maintain a resource list for specialty referrals, including eligibility criteria, referral process, cost, and contact information.
• Assist patients in locating and accessing low-cost prescription options (e.g., patient assistance programs, discount retailers).
• Assist with patient assistance program applications and serve as a patient-provider liaison with drug companies.
• Help patients apply for programs such as CoverRx and RxOutreach.
• Support other regional primary care-based initiatives with a social work component.
• Document in patient records, update consults, and tag providers or clinical staff as necessary.
• Provide patient education or find appropriate education resources.
• Participate in onboarding, orientation, and regional office or primary care clinical meetings as requested.
• Attend provider meetings, Health Councils, and other community meetings to build relationships with social service agencies.
• Identify barriers to care or assistance experienced by patients and seek ways to address them.