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. Currently licensed as a Registered Nurse and experience equivalent to one year of registered nursing. Or Currently licensed as a Registered Nurse and education equivalent to a bachelor's or graduate degree in nursing from an accredited college or university or a diploma in registered nursing from an accredited school of nursing. Currently licensed as a Registered Nurse in the State of Tennessee or holds a privilege to practice in the State of Tennessee under the Nurse Licensure Compact (NLC). A valid motor vehicle operator license may be required. Under general supervision, is responsible for registered nursing duties of average difficulty based on based on a wide range of circumstances and performs related work as required. Provides nursing care and procedures according to physicians orders and nursing protocol. Administers medication according to the physician's orders and protocol. Evaluates possible side effects and the overall effectiveness of medication. Performs BLS (Basic Life support), CPR (cardiopulmonary resuscitation), and other emergency responses. Participates in emergency response setting.

Other office related equipment as required

PTY Tech LLC

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