Social Worker Care Coordination - Population Health

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Scheduled Weekly Hours:
40

Work Shift:
Days (United States)

Overview of the Role

As a Social Worker, your primary responsibility will be to deliver clinical care management services to eligible patients. You will coordinate care to achieve optimal health outcomes, enhance self-care capabilities, and minimize unnecessary healthcare costs. Collaborating as part of an Interdisciplinary Team (IDT) alongside the Ambulatory Care Manager (ACM) and Care Coordinator, you will ensure that the unique needs of each patient are recognized and addressed promptly. This role involves conducting comprehensive needs assessments, identifying barriers to care, and connecting patients with available resources and benefits.

This position is remote, primarily serving the Hampton Roads, VA area. While residing in the region is not mandatory, familiarity with local community resources is essential.

Key Responsibilities

• Manage a caseload of patients in accordance with departmental guidelines.
• Identify, enroll, and oversee patients in the Complex Case Management program.
• Create and execute care plans aimed at maximizing patient wellbeing, with regular reviews and updates as per departmental standards.
• Work collaboratively with ACM, primary care providers, specialists, and hospitalists to implement a patient-centered care strategy.
• Conduct assessments of social determinants affecting care and establish goals as part of the comprehensive care plan.
• Engage in patient outreach following established protocols and document interactions in the electronic medical record.
• Identify, initiate, and monitor necessary referrals to care and community resources.
• Manage resources to enhance care quality, improve patient experiences, and reduce unnecessary costs: ensuring the right care is delivered at the right time and place.
• Assist patients with advanced care planning and the completion of Advanced Directives.
• Document all communications with patients and/or care teams in the electronic medical record.
• Coordinate services for patients with disabilities and facilitate placements in post-acute rehabilitation or long-term care facilities.
• Act as an advocate for patients, addressing their primary physical and socioeconomic needs while linking them to appropriate community services.

This list is not exhaustive and may include additional responsibilities as assigned by your supervisor, with reasonable accommodations considered.

QualificationsEducational Background

• Bachelor’s Degree (required)
• Bachelor’s or Master’s Degree in Social Work (preferred)

Licensing and Certification

• Licensure as mandated by the state of practice
• Case Management certification, LSW, or LCSW (preferred)

Experience Requirements

• 2-3 years of experience in acute care, home health, or case management

Essential Skills and Abilities

• Strong interpersonal communication and negotiation skills.
• Proficient analytical, data management, and computer skills.
• Basic understanding of healthcare and health education across various life stages in a clinical setting.
• Able to work effectively with individuals, families, and groups.
• Knowledge of community resources and flexibility to work non-traditional hours.
• Team-oriented with strong organizational skills and attention to detail.
• Experience with database entry, electronic medical records, PowerPoint, and basic Excel skills is preferred.

Preferred Skills

• Proven success in enhancing the health of a specific patient population in an ambulatory or community setting.

Compensation

Salary Range:
Minimum: $26.82
Maximum: $41.57

Our Commitment to You

We are an equal opportunity employer dedicated to fostering a diverse and inclusive workplace. As part of our organization, you will be part of a mission that truly matters. We prioritize your well-being, both personally and professionally, and our benefits are designed to evolve with you and cater to your unique needs.

What We Offer

• Competitive salary, incentives, referral bonuses, and a 403(b) plan with employer contributions (when eligible).
• Comprehensive medical, dental, vision, and prescription coverage, along with HSA/FSA options, life insurance, mental health resources, and discounts.
• Paid time off, parental leave, FMLA leave, short- and long-term disability, and backup care for children and elders.
• Tuition assistance, professional development, and support for continuing education.

Benefits may vary based on market conditions and employment status.

Department Information

Care Coordination - Population Health Service Organization

We adhere to all federal and state regulations, including the requirements outlined in 41 CFR 60-1.4(a), 60-300.5(a), and 60-741.5(a). All applicants will be considered for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not face discrimination based on disability. If you would like to review a copy of our affirmative action plan or policy statement, please inquire. Individuals with disabilities seeking reasonable accommodations during the employment selection process are encouraged to reach out to our Talent Acquisition Team.