Social Worker 2

Social Worker 2

The Social Worker 2 will serve as part of the Clinical Care Team at the McNairy County Health Department, supporting primary care providers by addressing patients’ social determinants of health (SDOH) and coordinating access to essential medical and community services.

Bachelor’s degree in Social Work is required.

Key Responsibilities

Social Determinants of Health (SDOH) Navigation

• Conduct in-person or remote social needs screenings and assessments.
• Assist patients facing food insecurity, housing instability, and other social barriers.
• Develop and maintain resource lists including eligibility criteria, referral processes, and contact information.
• Collaborate with nurses, providers, and fellow social workers.
• Connect patients with housing, food programs, clothing assistance, mental health services, and other community resources.

Case Management

• Coordinate hospital discharge planning, follow-ups, and patient education.
• Obtain medical records from hospitals and specialists.
• Assist in securing necessary medical equipment.
• Monitor and follow up on care plans.
• Re-engage patients lost to follow-up or overdue for care.

Specialty Referral & Medication Assistance

• Schedule and track specialist and imaging referrals.
• Maintain referral resource lists including cost and eligibility details.
• Assist patients with low-cost prescription programs (CoverRx, RxOutreach, and patient assistance programs).
• Serve as liaison between patients, providers, and pharmaceutical companies when needed.

Additional Responsibilities

• Document patient interactions in medical records and update consults.
• Participate in meetings, community health councils, and regional initiatives.
• Identify and address barriers to care.