Care Coordinator/Case Manager/Social Worker

Job Summary

We are seeking a compassionate and detail-oriented Clinical Care Coordinator / Social Worker to support patients in a primary care setting. This role focuses on addressing Social Determinants of Health (SDOH), coordinating care, and connecting patients with community and healthcare resources. The Clinical Care Coordinator works closely with providers, nurses, hospitals, and community partners to ensure continuity of care and improved patient outcomes.

Key ResponsibilitiesSocial Support & SDOH Navigation

• Conduct in-person or remote social needs screenings for patients referred by providers or nursing staff
• Assist patients with access to community resources related to housing, food, transportation, clothing, mental health services, and other social needs
• Compile and maintain an up-to-date resource list including eligibility criteria, referral processes, and contact information
• Collaborate with providers, nurses, and other social workers to identify patient and community resources

Case Management & Care Coordination

• Support hospital discharge planning, follow-up, and patient education
• Assist with obtaining patient medical records from hospitals and specialty providers
• Coordinate access to medical equipment through community partners
• Conduct follow-ups on care plans and identify patients overdue or lost to follow-up

Referral & Prescription Assistance

• Schedule, coordinate, and track specialty and imaging referrals
• Maintain referral resource lists including cost, eligibility, and contact information
• Assist patients in locating low-cost prescription options and patient assistance programs
• Support applications for prescription assistance programs such as CoverRx and RxOutreach
• Act as a liaison between patients, providers, and pharmaceutical assistance programs

Documentation & Communication

• Document all patient interactions in the electronic medical record
• Update consults and communicate with providers and clinical staff as needed
• Provide patient education or connect patients to appropriate educational resources

Community & Program Support

• Participate in clinic meetings, provider meetings, and regional office meetings as requested
• Attend community meetings and Health Councils to build partnerships with social service agencies
• Identify barriers to care and recommend solutions to improve patient access and outcomes
• Support other primary care initiatives with a social work component as needed

Qualifications

• Bachelor’s degree in Social Work, Human Services, Public Health, or a related field (Master’s preferred)
• Experience in case management, care coordination, social work, or community health
• Knowledge of Social Determinants of Health (SDOH) and community-based resources
• Experience working in healthcare, primary care, or hospital settings preferred
• Strong communication, organizational, and documentation skills
• Ability to work independently and collaboratively within a multidisciplinary team

Job Types: Full-time, Contract

Pay: $24.00 - $30.00 per hour

Benefits:

• Health insurance
• Paid time off

Application Question(s):

• Have you worked directly with Social Determinants of Health (SDOH) such as housing, food insecurity, transportation, or mental health services?
• Are you experienced in coordinating hospital discharges, follow-ups, or obtaining medical records from hospitals or specialists?
• Have you assisted patients with referrals, community resources, or prescription assistance programs (e.g., patient assistance programs, low-cost medication options)?
• Are you comfortable documenting patient interactions in an electronic health record (EHR/EMR) and collaborating with providers and nursing staff?

Experience:

• Clinical Care Coordinator / Social Worker: 1 year (Required)

Work Location: In person