Registered Nurse 1 /Cookeville, TN (Hybrid),9+ 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: 1. Personal Computer 2. Telephone 3. Fax Machine 4. Printer 5. Scanner 6. Copy Machine 7. Calculator 8. Personal Vehicle Other office related equipment as required