Job Duties: The Clinical Care Team will take referrals from primary care providers and will work with the primary care team to accomplish the following tasks: Social support navigation for social determinants of health (SDOH) such as food insecurity, housing insecurity, etc. Performs tasks consistent with social work such as refer and coordinate services, identify risk factors, assess, and address relevant patient needs such as educational, medical, psychosocial, financial as needed to assess needs of clients.