Social Worker – Care Coordination, Population Health

🔥 7 minutes ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $26 - $41 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Bon Secours Mercy Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2018

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Bon Secours Mercy Health is a leading health care organization committed to transforming health care delivery and services through strategic innovation and compassionate care. Operating hospitals and clinical sites in the U. S. and Ireland, the organization focuses on extending health care access, improving patient outcomes, and enhancing value through emerging technologies and strategic partnerships. With a commitment to service and stewardship, Bon Secours Mercy Health also prioritizes enhancing the quality of life for underserved communities while advocating for sustainability. The organization’s initiatives include digital innovation, diversified growth through investments and partnerships, and providing high-value care across its core clinical operations.

📋 Description

• Provide clinical care management services to identified eligible patients • Coordinate care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care • Work with the Ambulatory Care Manager and Care Coordinator as part of the Interdisciplinary Team • Perform standardized comprehensive needs assessments • Identify and address barriers to care and align patients with available benefits and resources • Maintain a patient caseload according to department policies • Identify, enroll, and manage patients in the Complex Case Management program • Develop, implement, review, and update patient-centered care plans • Collaborate with ACMs, PCPs, specialists, and hospitalists • Assess social determinants of care and family situations • Conduct patient outreach and document 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 Advanced Directives • Coordinate services for disabled status and facilitate placement in post-acute rehabilitation or long-term care facilities • Advocate for patients’ physical and socioeconomic needs and connect them with appropriate community resources and services

🎯 Requirements

• Bachelor’s Degree in Social Work required • Master’s Degree or licensure as required by state of practice required • 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 • Ability to work well in a team setting • Personal computer skills • Experience with database entry and EMR documentation • Basic Excel skills • High organization and attention to detail • Ability to accept responsibility and follow through on projects and activities • Case Management certification, LSW, or LCSW preferred • PowerPoint experience preferred • Demonstrated success improving the health of a distinct patient population in an ambulatory or community setting preferred

🏖️ Benefits

• Competitive pay • Incentives • Referral bonuses • 403(b) with employer contributions (when eligible) • Medical coverage • Dental coverage • Vision coverage • Prescription coverage • HSA/FSA options • Life insurance • Mental health resources and discounts • Paid time off • Parental leave • FMLA leave • Short-term disability • Long-term disability • Backup care for children and elders • Tuition assistance • Professional development support • Continuing education support