Social Worker - Leading Industry Pay

•  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 nurses and providers
• Provide in-person or remote social needs screening/assessment with primary care patients referred by a 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

• Work with hospitals for discharge planning, follow-up, and education
• Assist with obtaining patient records from hospitals
• Assist in securing needed medical equipment through community partners
• Conduct follow-ups on care plans
• Identify patients lost to follow-up or overdue for care and assist them in returning to care

• Schedule, coordinate, and track non-BCS specialist and imaging referrals.
• Assist with obtaining patient records from specialists and imaging centers.
• Compile and maintain resource list for specialty referrals including eligibility criteria, referral process, cost, and contact information.

• May assist with patient assistance program applications and serve as a patient-provider liaison with drug companies
• Assist patients 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

• 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.

• Personal Computer
• Telephone
• Fax Machine
• Printer
• Scanner
• Copy Machine
• Calculator
• Personal Vehicle

Ohm Systems, Inc. specializes in IT and Healthcare staffing services, dedicated to linking highly skilled professionals with our public and private clients across the United States. Our track record showcases our commitment to delivering outstanding staffing and consultancy solutions to our clients. We prioritize diversity and inclusivity and take pride in being an employer that promotes equal opportunities and affirmative action. Our goal is to foster an inclusive work environment that embraces individuals from all backgrounds, irrespective of their gender, race, or orientation.