Job Description

Essential Functions:

• Conducts psychosocial assessments and social determinant of health screenings and responds to referrals from providers and other Spectrum staff
• Provides comprehensive patient education on and resource referrals for identified social determinant of health and other psychosocial needs including financial/food/housing/transportation insecurity, interpersonal violence, immigration concerns, and educational needs
• Assists patients in understanding their diagnoses, treatment options, and resources available to them. Provides support for advanced care planning
• Troubleshoots barriers to adhering to plan of care
• Meets with patients in office to identify patient needs/concerns and making warm/lukewarm handoffs to internal and external resources
• Assist with form completion and applications for benefits and services
• Conducts phone outreach and follow-up to referred/identified patients
• Conducts transitions of care outreach to patients recently discharged from the ED or hospital
• Provides longitudinal follow-up support to target patients and populations per the needs of the care management program
• Assists with referrals to skilled home care services and home health aides
• Navigates cultural and language barriers to assist patients in effectively obtaining needed health care and other services inside and outside of Spectrum
• Coordinates with financial counselors to assist uninsured patients in applying for health insurance, emergency medical assistance, and emergency medication coverage.
• Assists with medication access matters and coordination with the 340b pharmacy and program manager
• Provides individual and family support and referral as necessary to resolve emotional and psychosocial problems.
• Documents all patient contacts, case updates and referrals in the medical record according to established protocols and standards.
• Audits medical record outcomes related to area of expertise.
• Prepares reports and audits requested by the supervisor.
• Builds relationships with community resources external to Spectrum.
• Coordinates organizational outreach and education activities to include community presentations and participation in health fairs as required.
• Serves on special committees and performs other duties as assigned.

Minimum Qualifications and Experience:

• Bachelor’s degree in Social Work, Sociology, Anthropology, Psychology, Ethnic Studies, other Social Science, or related field preferred
• At least one (1) year experience in benefit navigation, resource coordination, case management or clinical experience in ambulatory healthcare
• Professional or volunteer experience working with a multilingual, multicultural patient/client population
• Comfort communicating through telephonic, video, and in-person interpreters - REQUIRED
• Bilingual in English and at least one of the following: Spanish, Haitian Creole, Mandarin, Arabic, Russian, Ukrainian, or Portuguese preferred but not required
• Basic knowledge of public benefits, community resources, and immigration resources in Philadelphia area preferred
• Knowledge of Word and EXCEL spreadsheet software applications - REQUIRED
• Knowledge in accessing and using the Internet - REQUIRED
• Ability to be flexible and work at all center locations as required.