Social Worker- Ambulatory

Job Description

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary:

The Ambulatory Social Worker supports the Population Health team by addressing behavioral health needs and social determinants of health (SDOH) that impact patients’ ability to engage in care and achieve optimal health outcomes. This role primarily supports patients receiving care within primary care practices and works collaboratively with the interdisciplinary care team to identify and address psychosocial barriers to care.

The Ambulatory Social Worker conducts psychosocial and SDOH assessments, assists patients in navigating healthcare and community systems, and connects patients with appropriate social services and community resources. The role emphasizes care coordination, patient engagement, and support for individuals with complex medical, social, and behavioral health needs.

Responsibilities:

• Conducts psychosocial and social determinants of health (SDOH) assessments for patients identified through population health initiatives or provider referral.
• Identifies barriers to care related to behavioral health, social needs, and access to healthcare services.
• Provides short-term supportive counseling, problem-solving support, and motivational guidance to assist patients in engaging with care plans.
• Connect patients with appropriate community resources, social services, and assistance programs.
• Coordinates care with primary care providers, behavioral health clinicians, specialists, and community partners as appropriate.
• Assists patients in navigating healthcare systems, insurance coverage, and community-based services.
• Supports care transitions and follow-up for patients with complex social or behavioral health needs.
• Participates in interdisciplinary team meetings and population health initiatives aimed at improving patient outcomes.
• Maintains accurate and timely documentation of assessments, care coordination activities, and resource referrals within the electronic health record.
• Tracks and reports on patient engagement and care management activities as required by population health programs.

Other information:

Qualifications

Required

· Bachelor’s or Master's Degree in Social Work from an accredited program (BSW or MSW).

· Knowledge of social determinants of health and community resource systems.

· Experience working with diverse patient populations and individuals with complex social or behavioral health needs.

· Strong communication, care coordination, and problem-solving skills

· Ability to work collaboratively within an interdisciplinary healthcare team

Preferred

· Prior experience in ambulatory healthcare, primary care, or population health programs

· Experience with care management, case management, or community resource coordination

· Familiar with Electronic Health Record systems

Working Relationships

This position works closely with primary care providers, nurses, behavioral health clinicians, care coordinators, and other members of the population health team. The Ambulatory Social Worker may also coordinate with specialty providers and community agencies to support patients’ medical, behavioral health, and social needs.

Job Details

Legal Employer: Pardee - HCHC

Entity: Pardee UNC Health Care

Organization Unit: PBMD Population Health

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Hybrid

Work Schedule: Day Job

Location of Job: DR PARK

Exempt From Overtime: Exempt: No

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.