Outpatient Social Worker - Irmc Physician Group- Full Time

Responsibilities

• Provides services to patients referred from specialty practices, inpatient, hospital clinics, and primary care based on identified psychosocial, behavioral health, SDOH, or care coordination needs.
• Completes psychosocial and SDOH assessments to identify barriers affecting health, treatment adherence, access to care, and overall well-being.
• Assist patients and families with accessing community resources, financial assistance programs, transportation, food resources, housing supports, insurance-related resources, medical equipment, and other identified services.
• Provides care management and care coordination for patients with complex medical, psychosocial, or social needs.
• Collaborates with members of the interdisciplinary healthcare team.
• Provides brief supportive interventions and assists with behavioral health and substance use screening, referral, and connection to appropriate treatment services.
• Supports patients with chronic and complex medical conditions by identifying barriers to care and assisting with coordination of services and treatment recommendations.
• Facilitates referrals and communication between primary care, specialty care, behavioral health, hospital services, community agencies, and other healthcare providers.
• Provides ongoing follow-up with patients and families as appropriate to assess progress, reinforce treatment goals, and address changing needs.
• Advocates for patients and families to promote access to appropriate healthcare, community services, and supportive resources.
• Provides education to patients and families regarding available programs, services, and community resources.
• Maintains timely and accurate documentation of assessments, interventions, referrals, care coordination activities, and patient outcomes in the medical record.
• Communicates significant patient needs, barriers, and concerns to the appropriate healthcare provider and interdisciplinary team.
• Participates in interdisciplinary care planning, population health initiatives, quality improvement activities, and programs designed to improve patient access and health outcomes.
• Develops and maintains knowledge of community, regional, and healthcare resources relevant to the populations served.
• Establishes collaborative relationships with community agencies and healthcare organizations to improve coordination and continuity of services.
• Performs other duties consistent with the scope and responsibilities of the position.

Education and Qualifications

• Bachelor's degree in Social Work, Human Services, Rehabilitation, Psychology, Sociology, or a related human services field required.
• Master's degree in Social Work or a related human services field preferred.
• Experience in healthcare, primary care, specialty care, behavioral health, case management, community services, or care coordination preferred.