Primary Care Social Work Case Manager
Core
Provides social work case management support to a Primary Care program, addressing psychosocial needs of patients with chronic conditions via telephonic and video visits.
Role type
Primary Care Social Work Case Manager
Builds
Patient-centered care plans and support for high-needs patients
Domain
Healthcare / Primary Care / Virtual Care
Required skills
Social work case management, psychosocial screening, long-term care planning, advance care planning, interdisciplinary collaboration, electronic health record documentation, behavioral health navigation
Preferred skills
Medicare Advantage experience, geriatrics experience, bilingualism (English/Creole/Spanish/Vietnamese)
Technologies
Electronic health records, Google Office, Slack
Responsibilities
Conduct telephonic and video visits with patients and caregivers, build strong relationships with patients, collaborate with clinicians and nurses, develop personalized care plans, provide emotional and caregiver support, navigate social determinants of health, facilitate joint visits, participate in team huddles and program reviews, document clinical interactions
Seniority
Mid-level, hands-on IC