At VillageMD, we are committed to helping patients achieve greater health by delivering the most effective, accessible and efficient healthcare in the world through partnership with primary care physicians. We're in a unique position to impact everyone in primary care from independent, family-owned practices to world-class health systems. As an extension of the Primary Care Physician’s (PCP) care team, Social Work Care Managers are responsible for providing a variety of care management services within a PCP practice(s) or a patient’s home, targeting patients identified as high-risk and/or those who are experiencing barriers to meeting their healthcare goals. Principle care management services include, but are not limited to, performing comprehensive assessments, developing patient-centered care plans, and providing episodic and longitudinal care planning.

Integral to our care management team, the Social Work Care Manager will be responsible for addressing Social Determinants of Health (SDOH), addressing the behavioral health needs of patients and families and for monitoring behavior modification in high risk patients through empowerment and teaching of self-management skills. As a new member of our team, you’ll work closely with our care team to connect the dots of collaborative patient care.

What are some unique responsibilities that you’ll have at VillageMD?

• Actively engage and collaborate with PCPs and office staff in identifying high-risk patients
• Employ motivational interviewing skills to elicit optimal member engagement/outcomes
• Perform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriers
• Communicate assessment findings, care plan goals, interventions and outcomes to PCP, patients and caregivers in a timely manner
• Maintain a working knowledge of community resources/agencies to address a wide variety of psychosocial needs members may experience
• Identify and support practice needs for structured on-site care coordination presence in alignment with program models
• Maintain a core understanding of population management as it specifically relates to high-risk patients

What will make you successful here?

• The ability to be flexible in an ambiguous and dynamic environment
• The ability to adapt quickly to changing demands in the healthcare industry
• A service orientation and a “can do” attitude
• A willingness to learn on your own and take initiative
• Displays strength-based approach to collaborative problem solving
• The ability to receive feedback and apply it to work performance
• Demonstrates consistently strong ethics and sound judgement
• Effectively engages diverse populations (age, ethnic groups, socio-economic levels, etc.) and provides culturally sensitive coaching, education and assistance to members and their families
• Experience in conflict management and problem resolution
• A low ego and humility; an ability to gain trust through strong communication and doing what you say you will do

What you might do in your first year:

• Address gaps in care for high risk patients engaged in care management services
• Utilize behavioral health screening assessments, identify symptoms of behavioral health and substance abuse concerns, and effectively make referrals to appropriate community resources
• Effectively support patients, families and caregivers in managing psychosocial barriers
• Document clinical interventions in applicable care management software systems
• Develop and maintain effective professional working relationships with assigned PCP practice(s)
• Engage patients in a variety of settings, determined by program models and initiatives

The following experience is relevant to us:

• Master’s degree in social work or a related discipline
• Bilingual in Spanish/English required
• Licensed Social Worker with licensure in the state of practice
• 2+ years of experience in a health care and/or behavioral health setting
• Foundation of social work ethics that informs a thoughtful, evidence-based approach
• Utilizing a variety of electronic health records including data capture, data mining and reporting

At VillageMD, we see diversity and inclusion as a source of strength in transforming healthcare. We believe building trust and innovation are best achieved through diverse perspectives. To us, acceptance and respect are rooted in an understanding that people do not experience things in the same way, including our healthcare system. Individuals seeking employment at VillageMD are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.