Social Worker – Care Coordination, Population Health
Job not on LinkedIn
🕒 July 18
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📋 Description
• Provide clinical care management services to eligible patients • Coordinate care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care • Work with the Interdisciplinary Team, Ambulatory Care Manager, and Care Coordinator to identify and address patient needs • Perform standardized comprehensive needs assessments • Identify and address barriers to care and align patients with benefits and resources • Maintain a patient caseload according to department policies • Identify, enroll, and manage patients in Complex Case Management • Develop, implement, periodically review, and update care plans • Collaborate with ACMs, PCPs, specialists, and hospitalists on patient-centered care plans • Assess social determinants of care and family situations, and develop goals • Conduct patient outreach and document in the electronic medical record • Identify, execute, and track referrals to care and community resources • Manage resources to improve care and patient experience and reduce unnecessary cost and utilization • Assist patients with advanced 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 and connect them with appropriate community resources and services
🎯 Requirements
• Bachelor’s Degree required • Licensure as required by state of practice required; VA state license required for this position • 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 and knowledge of community resources • Flexibility to work non-traditional hours • Personal computer skills • Experience with database entry and EMR documentation • Basic Excel skills • Highly organized and detail oriented • Ability to accept responsibility and follow through on projects and activities
🏖️ 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 and continuing education support
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