The clinical care team will take referrals from primary care providers. The team will work with the primary care team to accomplish various tasks. Social support navigation for social determinants of health will be provided. This includes addressing food insecurity, housing insecurity, and similar issues. A resource list for social determinants of health resources will be compiled and maintained. Eligibility criteria, referral processes, and contact information will also be documented. Collaboration with the primary care nurse and providers is essential. Social needs screening and assessment will be conducted for primary care patients. This will include in-person or remote assessments for referred patients. Coordination with social services resources will be arranged. Services may include housing, clothing, food, mental health services, and more. Collaboration with other social workers will help identify patient and community resources. Case management activities will be conducted as required. Work with hospitals for discharge planning, follow-up, and education will be necessary. Assistance will be provided in obtaining patient records from hospitals. Securing needed medical equipment through community partners will be part of the role. Follow-up on care plans will be conducted to ensure patient compliance. Identifying patients lost to follow-up or overdue for care is a key responsibility. Assisting these patients in returning to care is important. There may be involvement in specialty referral navigation as needed. Scheduling, coordinating, and tracking non-specialist and imaging referrals will be required. Assistance will be provided in obtaining patient records from specialists and imaging centers. A resource list for specialty referrals will also be compiled and maintained. This will include eligibility criteria, referral processes, costs, and contact information. Helping patients locate and access low-cost prescription options will be part of the duties. Patient assistance program applications may be assisted with, acting as a patient-provider liaison. Support for applications for programs such as CoverRx and RxOutreach will be provided. Other regional primary care-based initiatives with a social work component may be available. Documentation in the patient's record will be necessary. Updates to consults and tagging providers or clinical staff will be expected. Patient education or finding appropriate education resources is part of the role. Expectations include completing onboarding and orientation. Participation in regional office and primary care clinical meetings as requested is necessary. Attendance at provider meetings and community meetings is expected to build relationships. Identifying barriers to care or assistance experienced by patients is important. Seeking ways to address these barriers will be part of the responsibilities.
Tools and equipment: Personal computer, telephone, fax machine, printer, scanner, copy machine, calculator, personal vehicle, additional office-related equipment may be required.
City: Altamont, State: TN
We offer competitive benefits, including:
Disclaimer: Benefits eligibility, accrual rates, and usage limits may vary based on employment status, length of service, and work location. Paid Sick Leave is provided in strict accordance with applicable state and municipal mandates. Cynet Health reserves the right to modify, amend, or terminate any benefit plans at any time in accordance with applicable laws.
About Cynet Health: Cynet Health is a Joint Commission-accredited, Minority-Owned healthcare staffing agency headquartered in Sterling, Virginia, proudly serving healthcare facilities across the United States since its founding in 2010. As one of the nation's largest and fastest-growing healthcare staffing firms in the nation, we staff thousands of nursing, allied health, locum tenens, pharmacy, therapy, direct-hire, and non-clinical professionals across hospitals, clinics, long-term care facilities, labs and more. We're one of the most decorated staffing agencies in America-ranked a Top Travel Nursing Company by BluePipes, recognized among the fastest-growing and most diverse staffing firms by Inc. 5000, Staffing Industry, WBJ and USPAACC-and remain deeply committed to excellence, inclusion, and community impact.
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