**Description**

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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, a...