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. Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.