*The Clinical Care Team will take referrals from primary care providers and will work with the primary care team to accomplish the following tasks:*
* 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 nurses and providers
* Provide in-person or remote social needs screening/assessment with primary care patients referred by a 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 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,*equipment* such as patient assistance programs, discount retailers, etc.
* May assist with patient assistance program applications and serve as a patient-provider liaison with drug companies
* Assist patients 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 consultations, and tags provider and/or clinical staff as necessary
* Provide patient education or find appropriate education resources
*Expectations may include:*
* Complete onboarding and orientation
* Participate in regional office and primary care clinical meetings as requested
* Attend provider meetings as requested
* Attend Health Councils and other community meetings to build relationships with social service agencies and promote health department services
* Identify barriers to care or assistance experienced by our patients and seek ways to address them
*Tools and equipment:*
1.
Personal Computer
2.
Telephone
3.
Fax Machine
4.
Printer
5.
Scanner
6.
Copy Machine
7.
Calculator
8.
Personal Vehicle
Other office related equipment as required
Job Type: Contract
Salary: $25.
00 - $32.
00 per hour
Expected hours: 40 per week
Standard shift:
* Day shift
Weekly schedule:
* 5x8
* Monday to Friday
Experience:
* Nursing: 4 years (Required)
License/Certification:
* BLS Certification (Required)
* RN (Required)
Work Location: On the road