Social Worker

• Provides social work services to patients, their families and/or significant others through counseling, emotional support, assisting with environmental needs, crisis intervention, and group leadership.
• Complete a comprehensive assessment to develop a safe, realistic discharge plan of care appropriate for the patient, in consideration of psychosocial, emotional, and financial needs, and in collaboration with the care management team and documents in the electronic medical record.
• Assess changes in the physician’s plan of care and any impact on the discharge plan.
• Reviews discharge plan on an ongoing basis and communicates any changes to the appropriate party. Documents the discharge plan in the electronic medical record.
• Identifies potential problems with post-discharge care and/or initiates early referrals to promote proper utilization of hospital resources and timely transfer to the appropriate level of care.
• Explore and collaborate with resources within the hospital and community to meet defined patient needs and refers patients and/or families to resources including but not limited to income assistance programs, transportation services, meal assistance, etc.

Social Worker providing support and resources to patients and families in a healthcare setting

Social Worker, BSW

Social Worker providing support services to patients and families in a healthcare setting. Collaborating with medical teams for comprehensive care and addressing psychosocial needs.

• Provides psychosocial services to patients treated by the facility
• Works with the health care team to promote positive adjustment, rehabilitation and improved quality of life for patients
• Supports Fresenius Kidney Care (FKC) commitment to Quality Assessment and Improvement

Entry level MSW supporting patients with psychosocial services in dialysis care

Master Social Worker – MSW

Entry level MSW providing psychosocial services to dialysis patients while working within an interdisciplinary healthcare team. Focusing on quality of life improvements and patient support.

• Social Worker works in a collaborative role with all members of the health care team and community service agencies to coordinate care for Sentara Health Plan members to improve health outcomes.
• Assesses for barriers to compliance with the medical care plan and implements appropriate interventions to promote improved health and compliance with recommended therapy.
• Acts as a resource to assist members in need of community-based program assistance and empowers the member with the skills to navigate the process for obtaining appropriate medical care and community assistance.

Social Worker collaborating to improve health outcomes at Sentara Health Plans

Social Worker – Masters in Social Work (MSW) for Maternity/OBGYN

Social Worker collaborating with medical teams to enhance care for Sentara Health Plan members. Engaging with community services and assisting members in navigating health processes.

• Provide clinical care management services to identified eligible patients
• Coordinate care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care
• Collaborate with Interdisciplinary Team (IDT) along with Ambulatory Care Manager (ACM) and Care Coordinator
• Perform standardized comprehensive needs assessment, identifying and addressing barriers to care
• Develop and implement care plans to maximize wellbeing with periodic review and update
• Collaborate with ACM, PCPs, Specialists, and Hospitalists to implement a patient-centered care plan
• Perform situational and family assessment of social determinants of care
• Act as patient advocate to address primary physical and socioeconomic needs
• Document all communications with patient and/or care team in electronic medical record

Social Worker providing clinical care management for eligible patients at Bon Secours

Social Worker – Care Coordination, Population Health

Social Worker providing clinical care management services to patients at Bon Secours. Collaborating with teams to improve health outcomes and reduce care costs while working remotely.

• Provides social work services and discharge planning to patients and families
• Transitions patients to alternate levels of care
• Provides crisis intervention as needed

Social Worker providing support to hospice patients and families at Essentia Health

Hospice Social Worker

Social Worker providing social work services and discharge planning to patients and families in a healthcare setting. Focused on promoting wellness and supporting crisis intervention needs.

• Participate in activities related to care management program build, implementation, oversight, and delegation.
• Assist in ensuring compliance with CMS SNP Model of Care (MOC) expectations, NCQA standards, and Medicare Advantage regulatory requirements.
• Perform psychological, social and economic care management interventions for members with severe/persistent mental or emotional disorders.
• Perform telephonic behavioral health comprehensive assessments of members’ environmental, behavioral, psychological, economic and social factors.
• Assist in the development of individualized and culturally sensitive care plans in collaboration with the member’s assigned CM, identifying problems, interventions, barriers and goals.
• Performing telephonic re-assessments, care plan revisions and evaluating the effectiveness of the members’ care plan.
• Member of the ICT for members with SDOH and BH needs and participates in ICT meetings when appropriate.
• Recognizes early signs of a members’ decompensation that requires immediate case management intervention that promotes and motivates compliance with treatment plan.
• Serves as an additional point of contact during transitions of care.
• Co-manages member cases with the CM to address psycho-social, economic and cultural issues that may impact the members’ care needs.
• Serves as a primary socio-economic resource for the D-SNP Care Management Team.
• Documents in the members’ case accurately and timely to ensure coordination of the members’ care needs.
• Adheres to all CMS, Code of Federal Regulations, local/state/national regulatory requirements and guidelines as well as those outlined within the MOC.
• Collaborate with all members of the interdisciplinary care team to facilitate appropriate community resource assistance for members with identified needs.
• Screens, identifies, diagnoses, treats and manages mental health and/or substance abuse problems in patients and family members.
• Knowledge of hospital, medical center and/or health system resources to access and provide for patient care needs.
• Maintains a working knowledge of community agencies and resources and serves as a liaison between them and the healthcare system.
• Collaborates for appropriate resource and financial management which may include but is not limited to-financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination.

SNP Social Worker on health plan’s medical management team

SNP Social Worker – Peak

SNP Social Worker assisting in coordination of benefits with MA and Medicaid. Integral member of the health plan’s medical management team attending to community resources and member health needs.

• Coordinate benefits with MA and Medicaid
• Connect members to community resources
• Participate in activities related to care management program
• Ensure compliance with CMS SNP Model of Care expectations
• Perform psychological, social and economic care management interventions
• Assist in the development of individualized care plans
• Document in the members’ case accurately and timely
• Collaborate with the interdisciplinary care team
• Maintain knowledge of community agencies and resources

SNP Social Worker collaborating with medical management team to improve health outcomes

SNP Social Worker integral to health plan’s medical management team. Collaborating on member care, ensuring compliance and connecting to resources while improving health statuses.

• Support and advocate for patients undergoing dialysis
• Help patients understand their rights and responsibilities
• Guide patients in managing the physical, mental, emotional, and financial demands of End Stage Renal Disease
• Build meaningful relationships with patients and their families in an outpatient setting

Social Worker supporting dialysis patients at DaVita

Social Worker at DaVita providing guidance and support to patients facing End Stage Renal Disease. Advocating for patient rights while managing emotional and financial demands of treatment.

• Build meaningful and long-term relationships with patients and their families
• Support and advocate for patients in managing their conditions
• Guide patients in understanding their rights and responsibilities
• Help patients manage physical, mental, emotional and financial demands of End Stage Renal Disease

Social Worker supporting dialysis patients at DaVita's outpatient clinics

Social Worker providing support and advocacy for dialysis patients at outpatient clinics. Building long-term relationships with patients and guiding them through their health journeys within a team-focused environment.

• The clinical social worker provides psychosocial assessments, interviews, and/or treatments and discharge planning to patients and families.
• Conduct psychosocial assessments to evaluate emotional, social, and environmental factors affecting patients and families.
• Develop and coordinate comprehensive care transition plans in collaboration with the interdisciplinary team, ensuring appropriate resource utilization.
• Regularly reassess care plans and adjust as needed, with face-to-face coordination whenever possible.
• Maintain up-to-date knowledge of benefit plans, regulatory guidelines, and resources for cost-effective care.
• Ensure timely, accurate, and confidential documentation, meeting professional standards and federally regulated timelines for assessments and discharge plans.
• Provide supervision, teaching, and training for staff and students as needed.
• Advocate for patients and provide therapeutic interventions to support their adaptation to illness or life changes.

Clinical Social Worker providing psychosocial support in Home Care settings

Medical Social Worker – Home Care

Clinical Social Worker providing psychosocial assessments and support for patients in Home Care. Collaborating with healthcare teams and facilitating patient transitions in a home setting.

Social Worker jobs in Virginia

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Social Worker, BSW

Master Social Worker – MSW

Social Worker – Masters in Social Work (MSW) for Maternity/OBGYN

Social Worker – Care Coordination, Population Health

Hospice Social Worker

SNP Social Worker – Peak

SNP Social Worker – Peak

Social Worker

Social Worker

Medical Social Worker – Home Care