SDOH Referral Specialist

The SDOH Referral Specialist plays a critical role in our integrated care model. While our Community Engagement and Patient Advocacy teams work on the front lines to identify needs, this role is the "bridge" that ensures those needs are met. You will take ownership of identified Social Determinants of Health (SDOH) barriers—such as housing instability, food insecurity, or transportation gaps—and work relentlessly to connect patients with the specific community resources required to improve their health outcomes.

Key Responsibilities

Referral Management: Monitor and manage the incoming queue of SDOH referrals submitted by Community Engagement Specialists and Patient Health Advocates.

Resource Navigation: Research, identify, and vet local and national community resources (non-profits, government agencies, and social programs) tailored to the patient’s specific needs.

Patient Connection: Contact patients via phone or platform direct messaging to discuss identified resources, assess their readiness to engage, and provide education on how to access services.

Active Linkage: Go beyond "giving a phone number." You will facilitate warm handoffs, assist with application paperwork, and follow up to ensure the connection was successful.

Documentation: Maintain meticulous records in the [Electronic Health Record/Case Management System] regarding the status of referrals and patient outcomes.

Advocacy: Act as a liaison between the patient and community partners to troubleshoot barriers to service.

Required Qualifications & Skills

Experience: Preferred experience in social services, community health, patient navigation, or willingness to learn.

Resourcefulness: A "detective" mindset with the ability to find niche resources for complex social needs.

Communication: Exceptional interpersonal skills; ability to build rapport quickly with patients from diverse backgrounds and communicate effectively with community partners.

Organization: High level of comfort managing a high-volume caseload with strict attention to follow-up timelines.

Empathy & Resilience: A deep understanding of the systemic challenges patients face and a persistent attitude toward overcoming them.

Success Metrics

Closing the Loop: The primary metric for this role is not just referrals processed, but the percentage of referrals successfully resolved.