Social Worker 2

Social Worker 2 Jackson, TN / On‑Site, 12+ Months Responsibilities 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 (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 a 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 and discount retailers. May assist with patient assistance program applications and serve as a patient‑provider liaison with drug companies. Assist patients with applications for programs such as CoverRx and RxOutreach. May help with other regional primary care–based initiatives that have a social work component. Document in the patient’s record, update consults, and tag provider and/or clinical staff as necessary. Provide patient education or locate appropriate education resources. Expectations Complete onboarding and orientation. Participate in regional office and primary care clinical meetings as requested. Attend provider meetings as requested. Attend community meetings (e.g., Health Councils) 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. #J-18808-Ljbffr