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 pati...