Social Worker Case Manager

Job ID: 65637

Position: Social Worker 2

Client: TN DOH

Location: 810 W Church Street Greeneville Tennessee 37744-0159

Duration: 11 Months

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.

• 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 the 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 patients 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:

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