Job Details

Establish and maintain strong interpersonal relationships with patients, community organizations, team members, and partners to coordinate patient needs. Manage patient referrals defined by the care team & collaborate with the Medical Social Worker on action plan. Facilitate communication between all identified parties involved in patients care as needed (e.g., family members, caregivers, medical providers, community-based organizations)Form relationships with and build an inventory of local community organizations that may benefit our patients. Connect patients to state and local community resources related to housing, transportation, food, and activities of daily living among other social and physical barriers to health. Assist patients with completion of applications for accessing eligible benefits and resources. Promote goal setting and achievement to improve patients quality of life and self efficacy with patients. Goal definitions are agreed upon by the care team. Meet with pat...Health, Worker, Transportation, Medical, Retail, Healthcare, Patient