Registered Nurse

Registered Nurse 1Location: 1100 England Drive, Cookeville, Tennessee 38501Client: TN DOHDuration: 14 Months (Possibility of extension)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 informationCollaborate with primary care nurse and providersProvide in-person or remote social needs screening/assessment with primary care patients referred by nurse or providerCoordinate 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 resourcesConduct case management activitiesWork with hospitals for discharge planning, follow-up and educationAssist with obtaining patient records from hospitalsAssist in securing needed medical equipment through community partnersConduct follow-up on care plansIdentify patients lost to follow-up or overdue for care and assist them in returning to careMay assist with specialty referral navigationSchedule, coordinate, and track non-BCS specialist and imaging referralsAssist with obtaining patient records from specialists and imaging centersCompile and maintain resource list for specialty referrals including eligibility criteria, referral process, cost and contact informationAssist 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 companiesAssist patient with applications for programs such as CoverRx and RxOutreachMay help with other regional primary care-based initiatives with a social work componentDocuments in patient’s record, updates consults, and tags provider and/or clinical staff as necessaryProvide patient education or find appropriate education resourcesExpectations may include:Complete onboarding and orientationParticipate in regional office and primary care clinical meetings as requestedAttend provider meetings as requestedAttend Health Councils and other community meetings to build relationships with social service agencies and promote health department servicesIdentify barriers to care or assistance experienced by our patients and seek ways to address themTools and Equipment:Personal ComputerTelephoneFax MachinePrinterScannerCopy Machine