Social Worker Care Coordination - Population Health

In the capacity of a Social Worker, provide clinical care management services to identified eligible patients, coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care. Work as a member of Interdisciplinary Team (IDT) along with the Ambulatory Care Manager (ACM) and Care Coordinator to ensure the assigned patient’s individual needs are identified and addressed in a timely manner. Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources. This is a remote/work from home position, primarily supporting our Hampton Roads, VA market. Hire does not have to be living in the area, but will need to be familiar with the region and community resources.

Responsibilities

• Maintain a caseload of patients according to department policies.
• Identify, enroll and manage patients in program for Complex Case Management.
• Develop and implement care plans to maximize wellbeing with periodic review and update according to department protocols.
• Collaborate with ACM, PCPs, Specialists, and Hospitalists to effectively implement a patient-centered care plan.
• Perform situational and family assessment of social determinants of care and develop goals as part of the comprehensive care plan.
• Perform patient outreach according to established protocols and document in electronic medical record.
• Identify, execute, and track needed referrals to care and community resources.
• Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, and right time.
• Assist patient in advanced care planning to complete Advanced Directives.
• Document all communications with patient and/or care team in electronic medical record.
• Perform coordination of services for disabled status and/or facilitate placement in post-acute facility for rehabilitation or long term care.
• Act as patient advocate to address primary physical and socioeconomic needs and link patient to appropriate community resources and services.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Requirements

• Bachelor’s Degree (required).
• Bachelor’s or Master’s Degree in Social Work (preferred).
• Licensure as required by state of practice.
• Case Management certification, LSW or LCSW (preferred).
• 2-3 years acute care, home health or case management experience.

Skills

• Excellent interpersonal communication and negotiation skills.
• Strong analytical, data management and computer skills.
• Demonstrate basic knowledge of healthcare and health education across the lifespan in a practice health setting.
• Ability to work with individuals, groups and families.
• Familiarity and knowledge of Community Resources.
• Flexibility to work non-traditional hours.
• Works well in a Team Setting.
• Personal computer skills.
• Experience with database entry, EMR documentation, Power Point preferred and basic Excel skills.
• Highly organized and detail oriented.
• Accepts responsibility and follows through on projects and activities.
• Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting (preferred).

Pay

Range Minimum: $26.82 - Maximum: $41.57

Benefits

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

Benefits may vary based on the market and employment status.