Primary Care Medical Social Worker

Prevea Health•Green Bay, WI

7h•Onsite

About The Position

The Medical Social Worker provides comprehensive psychosocial assessment, counseling, and care coordination services to patients in an outpatient setting. This role focuses on identifying and addressing social determinants of health (SDOH) that impact patient well-being and access to care. The Medical Social Worker collaborates with interdisciplinary care teams to develop and implement patient-centered care plans, connects patients to community resources, and supports improved health outcomes and care continuity. This position supports multiple clinic locations and requires regular travel between sites to ensure consistent service delivery and patient support.

Requirements

Bachelor's Degree Bachelors of Social Work Required
Licensed as a Certified Social Worker in the state of Wisconsin Required
BLS (Basic Life Support) Certified within 90 Days Required
Knowledge of medical social work practices, care coordination models, and the impact of social determinants of health on patient outcomes.
Knowledge of community resources, public assistance programs, and healthcare delivery systems.
Skill in psychosocial assessment, counseling, and crisis intervention.
Skill in care coordination, case management, and resource navigation across multiple settings.
Skill in effective communication and collaboration with patients, families, and interdisciplinary care teams.
Ability to manage multiple priorities, maintain accurate documentation, and work independently across multiple clinic locations.
Ability to build rapport with diverse populations, advocate for patient needs, and maintain confidentiality and professional ethical standards.
Proficient in computer systems, with ability to learn new software through training

Nice To Haves

Master's Degree Masters of Social Work Preferred
1-3 years experience in healthcare, care coordination, or community-based work. Preferred
Experience working with diverse populations and addressing social determinants of health. Preferred

Responsibilities

Conduct comprehensive psychosocial assessments to identify patient needs, barriers to care, and social determinants of health impacting outcomes.
Provide counseling, emotional support, and crisis intervention to patients and families, promoting coping strategies and overall well-being.
Connect patients to community resources (e.g., housing, transportation, food, financial assistance, behavioral health) and advocate for access to needed services.
Develop, implement, and monitor individualized care plans in collaboration with interdisciplinary care teams to support patient-centered outcomes.
Coordinate care across healthcare settings and facilitate referrals to internal and external services, ensuring continuity of care and appropriate follow-up.
Educate patients and families on treatment plans, available resources, and self-management strategies to improve health outcomes.
Document patient interactions, care coordination activities, and outcomes in the electronic health record, while participating in care team meetings and maintaining knowledge of community resources and best practices; travel between clinic locations to provide consistent support.