Description

Provide clinical social work support in a primary care setting to address social determinants of health and coordinate patient care.

This role is on-site.

Responsibilities

• Navigate social support resources for food and housing insecurity.
• Conduct in-person or remote social needs screenings and assessments for referred patients.
• Manage case activities including hospital discharge planning, follow-up care, and medical equipment procurement.
• Coordinate specialty and imaging referrals by scheduling, tracking, and obtaining necessary medical records.
• Document all interactions in patient records, update consults, and provide patient education.

Required Skills

• 5+ years of professional experience in social work or related clinical care settings.
• Experience with case management and discharge planning.
• Ability to conduct social needs assessments and screenings.
• Knowledge of social determinants of health (SDOH) resource navigation.
• Proficiency using telephone and fax machine for clinical coordination.
• Competency in maintaining detailed patient documentation and medical records.
• Ability to manage specialty referral tracking and coordination.
• Ownership of patient assistance program applications and liaison duties.

Preferred Skills

• Experience working directly within a primary care clinical team.
• Familiarity with regional social service agency networks.

Key Skills

Education

Any Graduate