Social Worker – Care Coordination, Population Health

🔥 0 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $26 - $41 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Bon Secours

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🤝 Non-profit

Healthcare • Non-profit

Bon Secours is a mission-driven, not-for-profit health care organization that emphasizes compassionate, community-focused clinical care and support services. The organization recruits and trains staff for bedside care, patient support, community service, and administration, and highlights workforce development, flexible benefits, and a culture centered on dignity, unity, and service. Bon Secours presents itself as a faith-based/ministry-oriented health system focused on serving patients and communities with an emphasis on employee growth and total rewards.

📋 Description

• Provide clinical care management services to eligible patients to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care • Work as a member of the Interdisciplinary Team with the Ambulatory Care Manager and Care Coordinator • Perform standardized comprehensive needs assessments and identify barriers to care • Align patients with available benefits, community resources, and services • Maintain a patient caseload according to department policies • Identify, enroll, and manage patients in the Complex Case Management program • Develop, implement, periodically review, and update patient-centered care plans • Collaborate with ACMs, PCPs, specialists, and hospitalists • Perform situational and family assessments of social determinants of care • Conduct patient outreach and document communications in the electronic medical record • Identify, execute, and track referrals to care and community resources • Provide resource management to improve care and patient experience and reduce unnecessary cost and utilization • Assist patients with advance care planning and completion of Advance Directives • Coordinate services for disabled status and facilitate placement in post-acute rehabilitation or long-term care facilities • Act as a patient advocate addressing physical and socioeconomic needs

🎯 Requirements

• Bachelor’s Degree required • Master’s Degree or licensure as required by state of practice required • Bachelor’s or Master’s Degree in Social Work preferred • Case Management certification, LSW, or LCSW preferred • 2–3 years of acute care, home health, or case management experience • Excellent interpersonal communication and negotiation skills • Strong analytical, data management, and computer skills • Basic knowledge of healthcare and health education across the lifespan in a practice health setting • Ability to work with individuals, groups, and families • Familiarity with and knowledge of community resources • Flexibility to work non-traditional hours • Personal computer skills • Experience with database entry and EMR documentation • PowerPoint experience preferred • Basic Excel skills • Highly organized and detail oriented • Ability to accept responsibility and follow through on projects and activities • Demonstrated success improving the health of a distinct patient population in an ambulatory or community setting preferred • Hire does not have to live in the Hampton Roads area but must be familiar with the region and community resources

🏖️ Benefits

• Competitive pay • Incentives • Referral bonuses • 403(b) with employer contributions (when eligible) • Medical, dental, vision, and 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 • Continuing education support