Team Lead: Functions as supervisor of the team as well as fulfills the other duties outlined below.

· Creates work schedule of team members.

· Solicits feedback from primary care staff to identify and prioritize needs.

· Develops workflow for referrals, follow-up, tracking and other tasks in conjunction with regional and local health department leadership.

· Assists in data collection on efficacy of clinical care team.

· Functions within the team as a Social Worker or Social Counselor also performing the duties below.

· Performs tasks consistent with social work such as refer and coordinate services, identify risk factors, assess, and address relevant patient needs such as educational, medical, psychosocial, financial as needed to assess needs of clients.

Job Duties:

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.

o Compile and maintain a resource list for SDOH resources including eligibility criteria, referral process, and contact information

o Collaborate with primary care nurse and providers

o Provide in-person or remote social needs screening/assessment with primary care patients referred by nurse or provider

o Coordinate or make aware of social services resources, i.e., housing, clothing, food, mental health services, etc.

o Collaborate with other social workers to identify patient and community resources

· Conduct case management activities

o Work with hospitals for discharge planning, follow-up and education

o Assist with obtaining patient records from hospitals

o Assist in securing needed medical equipment through community partners

o Conduct follow-up on care plans

o Identify patients lost to follow-up or overdue for care and assist them in returning to care

· May assist with specialty referral navigation

o Schedule, coordinate, and track non-BCS specialist and imaging referrals

o Assist with obtaining patient records from specialists and imaging centers

o 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.

o May assist with patient assistance program applications and serve as a patient-provider liaison with the drug companies

o 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

Job Type: Contract

Pay: $27.00 - $30.07 per hour

Expected hours: 40 per week

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• In-person

Experience:

• clinical care: 1 year (Preferred)

License/Certification:

• BLS Certification (Preferred)
• RN (Preferred)

Ability to Commute:

• Chattanooga, TN 37402 (Preferred)

Ability to Relocate:

• Chattanooga, TN 37402: Relocate before starting work (Preferred)

Work Location: In person