The Social Worker for Community Health Initiatives provides professional services to clients and their families eligible for the Healthy Beginnings Services in order to meet identified psychosocial, emotional, financial and environmental needs. This SW will also serve patients/families on board the Mobile Health Clinic performing Social Determinants of Health and providing appropriate referrals/resources. The social worker provides psychosocial assessments, supportive counseling, emergent crisis intervention appropriate to setting, financial resource information, environment enhancements, advance directive planning and referrals to community agencies for clients and their caregivers/families in the client's home, mobile health clinic (MHC), or other settings. Using an interdisciplinary team approach, the social worker ensures clear communication and helps to facilitate care transitions. The social worker identifies and implements interventions at the individual and systemic levels and provides expertise to high risk clients across the continuum. The social worker works collaboratively with the multi-disciplinary team to support the RN performing at the highest level of their license in addition to maximizing the social worker's specialized training to address complex cases. Social Services are provided as part of a collaboration with interdisciplinary teams in adherence to the NFP model, and to policies, procedures, guidelines, and standards of NFP and of the Carle Health System.Involves client/patient/family in case planning decisions.Provides social work intervention to clients and their families eligible for the Healthy Beginnings and/or Mobile Health Clinic services.Helps to facilitate care transitions, referrals to scoial services, and other specialits when needed.Keeps the director/manager informed of problematic cases, especially those involving legal or risk management issues.Provides assistance and advocacy to clients in obtaining financial resources and government entitlements.Develops and maintains tracking system of social services referrals /outcomes.Provides information and counseling for advance directives and health care power of attorney.Provides social work intervention to patient/families eligible for the NFP Program.Responds to referrals from healthcare team members to identify available services for case specific needs.Collaborates with nurse home visitors / supervisors / mobile health clinic staff to meet the needs of high risk populations.Details (direct or incidental) possible to enhance service/care is communicated across service lines and among disciplines.Documents all client interactions, significant observations, interventions, and actions taken in the client's medical record in an appropriate and timely manner.Formulates, develops, and implements a plan utilizing appropriate social work interventions. Provides education and counseling to clients and families around issues related to adaptation to the client's illness and/or life situation. May utilize crisis intervention, brief and long-term individual, group, and family therapies.Assists clients and their families in establishing goals and outcomes through therapeutic relationships by providing education, support, and referral resources.Assesses physical, emotional, social, spiritual, and environmental needs of clients and their families as they relate to the NFP domains.As requested/required, participates in community coalitions and other community organizations in support of NFP as well as promotes public awareness of Healthy Beginnings Services and the Mobile Health Clinic.Facilitates education/training modules to assist RN staff managing basic social work needs.

The Certified Medical Assistant / Registered Medical Assistant performs routine administrative and patient care support duties in a medical practice to assist medical and/or nursing staff in the examination and treatment of patients and ensures that the office runs smoothly.Rooming patients: Collecting pertinent information regarding the patient's chief complaint, family history, social history, surgical history, and medication reconciliation upon arrival for a patient visit.Telephone Interactions: As directed, completing necessary telephone communications with patients, families, pharmacies, and/or other health care facilities. Gathering information and maintaining patient information via telephone per department specific processes and policies.Administrative tasks including, but not limited to, patient check in or check out, prior authorizations, scheduling appointments, verification of benefits, and coordination of referrals and testing.Office procedures as directed and per department specific competencies. May perform procedures such as urine catheterizations, bladder scanning, suture or staple removal, application or removal of casts at the direction of a provider, reading results of negative TB skin tests or steering patient to the care of a department nurse when TB screening appears to have indications of a positive read, and other diagnostic testing at the point of care.Provide patient with written instructions regarding procedures, medications, or follow up instructions at the direction of the provider. CMA staff may retrieve and provide condition specific education from the internet, internal website, or printed materials per the provider directions and orders.Administer medications per the provider order.Provide assistance with prescription medication refills per department protocols. Call medications into pharmacies, notify patients of refills, and documents actions within the EMR per provider orders.Maintain department specific competencies related to point of care testing, equipment handling, and specialty training.Performs all essential functions of MA.Responsible for billing procedure.Obtaining prior authorization for specialty medications.Refilling medications per department protocol.Contacting patients with normal results.

The Certified Medical Assistant / Registered Medical Assistant performs routine administrative and patient care support duties in a medical practice to assist medical and/or nursing staff in the examination and treatment of patients and ensures that the office runs smoothly.Rooming patients: Collecting pertinent information regarding the patient's chief complaint, family history, social history, surgical history, and medication reconciliation upon arrival for a patient visit.Telephone Interactions: As directed, completing necessary telephone communications with patients, families, pharmacies, and/or other health care facilities. Gathering information and maintaining patient information via telephone per department specific processes and policies.Administrative tasks including, but not limited to, patient check in or check out, prior authorizations, scheduling appointments, verification of benefits, and coordination of referrals and testing.Office procedures as directed and per department specific competencies. May perform procedures such as urine catheterizations, bladder scanning, suture or staple removal, application or removal of casts at the direction of a provider, reading results of negative TB skin tests or steering patient to the care of a department nurse when TB screening appears to have indications of a positive read, and other diagnostic testing at the point of care.Provide patient with written instructions regarding procedures, medications, or follow up instructions at the direction of the provider. CMA staff may retrieve and provide condition specific education from the internet, internal website, or printed materials per the provider directions and orders.Administer medications per the provider order.Provide assistance with prescription medication refills per department protocols. Call medications into pharmacies, notify patients of refills, and documents actions within the EMR per provider orders.Maintain department specific competencies related to point of care testing, equipment handling, and specialty training.Performs all essential functions of MA.Responsible for billing procedure.Obtaining prior authorization for specialty medications.Refilling medications per department protocol.Contacting patients with normal results.