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.