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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Mercy Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🤝 Non-profit

Healthcare • Non-profit

Mercy Health is a mission-driven healthcare organization that provides direct patient care, community health services and a range of support and administrative roles. The organization emphasizes the human side of health care, compassionate, values-based service tied to a ministry mission, workforce development for bedside and support staff, flexible benefits and community outreach. Mercy Health positions itself as both an employer and community health provider focused on dignity, unity and social service.

📋 Description

• Provide clinical care management services to eligible patients to coordinate care, improve self-care abilities, and reduce unnecessary costs. • Work with the Ambulatory Care Manager, Care Coordinator, PCPs, Specialists, and Hospitalists as part of an Interdisciplinary Team. • Perform comprehensive needs, situational, and family assessments, including social determinants of care. • Identify and address barriers to care and connect patients with benefits, community resources, and services. • Maintain a patient caseload and enroll and manage patients in Complex Case Management programs. • Develop, implement, periodically review, and update patient-centered care plans. • 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, patient experience, and utilization. • Assist patients with advanced care planning and completion of 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. • Perform other job-related duties as required by the supervisor.

🎯 Requirements

• Bachelor's Degree 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. • Case Management certification, LSW, or LCSW preferred. • 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 in a team setting. • Personal computer skills. • Experience with database entry and EMR documentation. • Basic Excel skills. • PowerPoint experience preferred. • Highly organized and detail-oriented. • Accepts responsibility and follows 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 coverage • Dental coverage • Vision coverage • Prescription coverage • HSA/FSA options • Life insurance • Mental health resources • Discounts • Paid time off • Parental leave • FMLA leave • Short-term disability • Long-term disability • Backup care for children and elders • Tuition assistance • Professional development • Continuing education support