Job Description

The Clinical Care Team will receive referrals from primary care staff and will work collaboratively to carry out the following responsibilities:

• Perform case management activities, including:
• Connecting patients to relevant social service resources such as housing, clothing, food, and mental health services.
• Assisting with securing necessary medical equipment.
• Following up on patient care plans to ensure continuity of care.
• Maintain an up-to-date directory of community resources for each county, including eligibility criteria, referral processes, and contact information.
• Support patient education by providing referrals or identifying appropriate educational materials and resources.
• Conduct in-person or virtual social needs screenings and assessments for primary care patients referred by providers.
• Document all activities and communications in the patient’s medical record, coordinating with providers and clinical staff as needed.
• Assist with patient outreach, including identifying high-risk patients who are lost to follow-up or overdue for care, and supporting their return to services as directed by providers.
• Travel throughout the region as necessary to support clinic operations and patient needs.

Additional Expectations:

Expectations will be communicated by the Regional Leadership Team and may include:

• Completing all onboarding and orientation activities.
• Participating in provider and nursing supervisor staff meetings as appropriate.
• Attending Health Council and other community meetings to build partnerships with social service agencies and promote health department services.
• Identifying and addressing barriers to care or assistance that impact patients’ access to needed services.

Job Requirements:

Education and Experience: Graduation from an accredited college or university with a bachelor's, master's, or doctorate degree in social work and one year of full-time professional social work or social work-related experience.

Substitution of Education for Experience:

• Qualifying graduate coursework in social work from an accredited college or university may be substituted for the required year of experience. (e.g., 36 graduate quarter hours in social work may be substituted for the one year of required experience).
• Relevant full-time public health experience involving direct client services, community outreach, case management, or care coordination may also be considered in substitution for the required social work-related experience

OR

Possession of a Master of Social Work Certificate (CMSW) or License of Clinical Social Work (LCSW) from the State of Tennessee

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