Social Worker – Care Coordination, Population Health

🕒 August 7

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $26 - $41 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 35%

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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 • Coordinate care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary care costs • Work with the Ambulatory Care Manager and Care Coordinator as part of an Interdisciplinary Team • Perform standardized comprehensive needs assessments • Identify and address barriers to care and connect patients with benefits and resources • Maintain a patient caseload • Identify, enroll, and manage patients in Complex Case Management • Develop, implement, periodically review, and update patient care plans • Collaborate with ACMs, PCPs, specialists, and hospitalists on patient-centered care plans • 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 • Advocate for patients’ physical and socioeconomic needs and connect them with community resources

🎯 Requirements

• Bachelor’s Degree (required) • Licensure as required by state of practice (required); VA state license required for this position • 2–3 years 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 • Highly organized and detail oriented • Accepts responsibility and follows 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 • Continuing education support