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.

• 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 pa...