Registered Nurse/Cookeville, TN (Hybrid),3+ Months Contract

Clinical Care Team Member

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 patient's 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: Personal Computer, Telephone, Fax Machine, Printer, Scanner, Copy Machine, Calculator, Personal Vehicle Other office related equipment as required