Social Worker​/Case Manager

Location: Altamont

Job Duties:

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. o Compile and maintain a resource list for SDOH resources including eligibility criteria, referral process, and contact information o Collaborate with primary care nurse and providers o Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider o Coordinate or make aware of social services resources, i.e., housing, clothing, food, mental health services, etc.

o Collaborate with other social workers to identify patient and community resources
· Conduct case management activities o Work with hospitals for discharge planning, follow-up and education o Assist with obtaining patient records from hospitals o Assist in securing needed medical equipment through community partners o Conduct follow-up on care plans o Identify patients lost to follow-up or overdue for care and assist them in returning to care
· May assist with specialty referral navigation o Schedule, coordinate, and track non-BCS specialist and imaging referrals o Assist with obtaining patient records from specialists and imaging centers o 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. o May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies o Assist patient with applications for programs such as Cover Rx and Rx Outreach  
· May help with other regional primary care-based initiatives with a social work component