Summary:
The Clinical Care Team Social Worker collaborates with primary care providers to address social determinants of health (SDOH) and improve patient outcomes. This role involves social support navigation, case management, resource coordination, and patient education to help individuals access essential services and maintain continuity of care.

Position Info:

• Title: Social Worker 2
• Client: TN DOH
• Duration: 12 Months
• Location: 1100 England Dr, Cookeville TN Cookeville, Tennessee 38501
• Work Mode: Onsite

Responsibilities:

• Conduct social needs assessments and connect patients with resources for housing, food, mental health, and other SDOH.
• Compile and maintain resource lists, including eligibility criteria and referral processes.
• Collaborate with primary care providers, nurses, and other social workers to coordinate patient care.
• Manage cases, including hospital discharge planning, follow-up care, and securing medical equipment.
• Support specialty referral navigation by scheduling, coordinating, and tracking patient appointments.
• Assist patients with access to low-cost prescription programs and complete program applications.
• Document patient interactions and maintain accurate records in compliance with care standards.
• Participate in community meetings, provider meetings, and health councils to build relationships with social service agencies.

Skills/Qualifications:

• Strong understanding of social determinants of health and community resource navigation.
• Ability to perform social needs assessments and develop care plans.
• Experience with case management, hospital discharge planning, and specialty referrals.
• Proficiency in documentation and maintaining detailed patient records.
• Effective collaboration skills for working with primary care teams, social workers, and community partners.
• Familiarity with patient assistance programs for medications and medical equipment.
• Access to a personal vehicle and willingness to travel as needed for patient care or community meetings