Social Work Care Manager (Village at Home)
Join VillageMD as a Social Work Care Manager in Phoenix, AZ
Join the frontlines of today's healthcare transformation
At VillageMD, we're looking for a Social Work Care Manager to help us transform the way primary care is delivered and how patients are served. As a national leader on the forefront of healthcare, we've partnered with many of today's best primary care physicians. We're equipping them with the latest digital tools. Empowering them with proven strategies and support. Inspiring them with better practices and consistent results.
We're creating care that's more accessible. Effective. Efficient. With solutions that are value-based, physician-driven and patient-centered. To accomplish this, we're looking for individuals who share our sense of excellence, are ready to embrace change, and never settle for the status quo. Individuals who have the confidence to lead but the humility to never stop learning.
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), a patient’s home, or a community setting, targeting physically, socially, and behaviorally complex patients. Social Work Care Managers understand basic pathophysiology of chronic conditions and are comfortable in symptom screening and education, escalating to RNs, PharmD and PCPs when appropriate. Successful patient outcomes require skillsets in Motivational Interviewing, patient engagement and empowerment and coaching/teach-back methods for self-management. Using standard assessments & evidence-based screenings, Social Work Care Managers develop unique patient-centered care plans, collaborating with
patient’s, their support systems and community service programs. A successful Social Work Care Manager is a systems thinker and is skilled at thinking outside of the box for solutions to complex problems impacting patients and their caregivers.
What are some unique responsibilities that you’ll have at VillageMD?
• Actively engage and collaborate with PCPs and office staff in identifying at-risk patients
• Employ motivational interviewing skills to elicit optimal patient engagement and outcomes
• Meets with patients and caregivers face to face either in the clinic, patients home, or community settings
• Develop deep relationships with patients and their caregivers, serving as a partner to improved quality of life through admission and readmission avoidance
• Perform comprehensive screenings for both physical and psychosocial risk factors combined with data to help inform a wholistic view of patient’s status and inform care planning
• Provide brief therapeutic interventions to patients with behavioral health needs, meanwhile connecting them to long term support
• Provide symptom management coaching to patients with medical and social complexities
• Evaluate services and resources provided to patients to determine effectiveness, and modify treatment plan and recommendations as necessary
• Educating patients and caregivers about Advance Care Planning (ACP) and facilitating the in completion of required documents
• Collaborate with PCPs, RNs and PharmDs for patients with medical complexities
• Prioritizes patients for and participates in multidisciplinary team meetings
• Assess and address care gaps that may be mitigated by additional education and/or connection to community based services
• 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
• Collaborate with hospitals, SNF (Skilled Nursing Facilities), home health, and durable medical equipment agencies for safe and effective discharge planning
• At market leadership discretion, aid in the oversight of home health recertifications and preferred vendor relationships, engaging and providing timely updates to Primary Care Physicians
• 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/complex patients
• Maintain current knowledge of community, state and federal programs and support patients in engaging with programs in which they qualify
What will make you successful here?
• Strong Motivational Interviewing and rapport building skills
• A passion for changing the way healthcare is experienced for complex and/or disadvantaged patients and communities
• Demonstrated strength-based approach to collaborative problem solving
• Effective engagement of diverse populations (age, ethnic groups, socio-economic levels, etc.) and provides culturally sensitive coaching, education and assistance to patients and their families
• Experience in conflict/crisis management and problem resolution
• Comfortability and skilled at Advance Care Planning conversations
• Demonstrated strong ethics and sound judgement guided by the NASW code of ethics
• 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
• The ability to receive feedback and apply it to work performance
• A low ego and humility; an ability to gain trust through strong communication and doing what you say you will do
The following experience is relevant to us:
• Master’s degree in Social Work
• Licensed Clinical Social Worker (or state equivalent) with unincumbered licensure in the state of practice or plan to receive licensure w/in 12 months of hire, preferred
• 2+ years of experience in a health care setting. Ideal candidate will have experience working in a Primary Care setting, in/with SNFs, discharge planning, and/or working in a hospital setting performing case management responsibilities
• Valid drivers license and personal transportation for community visits
• Experience working with patients with varying physical, behavioral or social complexities preferred.
• Foundation of social work ethics that informs a thoughtful, evidence-based approach
• Experience documenting in a variety of electronic health records
How you will thrive
In addition to competitive salaries, a 401k program with company match and a valuable health benefits package, VillageMD offers paid parental leave, pre-tax savings on commuter expenses, and generous paid time off. You work in a highly-collaborative, conscientious, forward-thinking environment that welcomes your experience and enables you to make a significant impact from Day 1. Most importantly, you make a difference. You see a clear connection between your daily work on VillageMD products and services and the advancement of innovative solutions and improved quality of healthcare for providers and patients.
Our unique VillageMD culture – how inclusion and diversity make the difference
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. Those 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.
Explore your future with VillageMD today.