Job Description

Daily Responsibilities

This role supports a panel of patients as part of a multidisciplinary primary care team, helping individuals navigate preventive, chronic, and acute care needs. The position focuses on patient engagement, education, advocacy, and care coordination to improve health outcomes and promote long-term wellness.

Key Responsibilities

• Build and maintain supportive, trust-based relationships with patients and families in clinical and community settings
• Engage patients in their care plans and encourage active participation in health and lifestyle decisions
• Conduct health risk and social needs assessments and document patient interactions accurately
• Collaborate closely with medical providers, nurses, behavioral health, and care coordination teams
• Educate patients on acute and chronic condition management and preventive care
• Advocate for patients by supporting appointments and care transitions when needed
• Coach patients using motivational interviewing and action-planning techniques
• Assist with care coordination, including scheduling, referrals, and information sharing
• Communicate with patients via phone, video, text, and in person
• Support daily clinic operations and track patient enrollment and program progress
• Perform additional duties as assigned

Requirements

• Bachelor's degree (required)
• Master’s degree (preferred)
• LCSW (preferred)
• 3-5 years of Social Work experience in a clinical setting
• Experience working with adults and geriatrics
• Bilingual in English and Spanish
• Tech savvy

Hours: M-F 8AM-5PM

Location: North Austin 78753

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