Job Id: 63360

Position: Social Worker 2

Client: TN DOH

Location: 140 Dover Street Shelbyville, Tennessee 37160

Duration: 9+ Months

Shift: 8:00 Am to 4:30 Pm (Hybrid)

Job Description:

• 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 and housing insecurity.
• 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 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

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:

• Personal Computer
• Telephone
• Fax Machine
• Printer
• Scanner
• Copy Machine
• Calculator
• Personal Vehicle
• Other office related equipment as required