Description

Provide clinical social work support to primary care patients by addressing social determinants of health and coordinating essential community resources.

Conduct in-person or remote social needs screenings and assessments for patients referred by primary care providers. Manage social support navigation for food insecurity, housing insecurity, and other social determinants of health. Execute case management activities, including discharge planning, follow-up care, and patient education. Coordinate specialty and imaging referrals, including scheduling, tracking, and obtaining necessary medical records. Maintain updated resource lists for SDOH and specialty referrals, including eligibility and contact details.

Responsibilities

• Conduct social needs screenings and assessments for referred patients.
• Manage navigation for food and housing insecurity.
• Execute case management, discharge planning, and patient education.
• Coordinate specialty referrals, scheduling, and medical records.
• Maintain resource lists and eligibility details for SDOH.

Required Skills

• 5+ years of professional experience in social work or a related clinical field.
• Proven ability to develop and follow care plans.
• Experience with case management and discharge planning in a clinical setting.
• Ability to navigate social service agencies and community resource networks.
• Experience managing patient assistance programs and prescription discount options.
• Strong documentation skills for maintaining accurate patient medical records.
• Ability to coordinate with multidisciplinary teams including nurses and primary care providers.

Preferred Skills

• Graduate degree in social work or related clinical field.

Key Skills

Education

ANY GRADUATE