Social Work Care Manager

About Our Company

We're a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.

Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.

When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.

Job Description

Join VillageMD as a Social Work Care Manager

Join the frontlines of today's healthcare transformation

Locations: Ann Arbor and surrounding area

Why VillageMD?

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 with our group of independent providers in the Ann Arbor area. 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 are experienced in basic behavioral health screenings such as PHQ9 and GAD tools, also 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?

• Leverage tools like Health Focus to identify and engage identified patients for specific care management programs such as CoCM and PDCM.

• Actively engage and collaborate with PCPs and office staff in identifying and managing 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, collaborating with the patients care team including psychiatry and PCP. Ensure patients establish relationships with long term supportive and therapeutic resources

• 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

• 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

• 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 building trusting and dynamic relationships with primary care providers and their office support staff

• 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

• Skilled at operating in different documentation platforms include EMRs, care management workflow tools and navigating excel files when necessary

• 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 unencumbered licensure in the state of practice or plan to receive licensure w/in 12 months of hire, preferred

• Candidates who are currently trained in CoCM and PDCM curriculum endorsed by MiCMT

• 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

About Our Commitment

Total Rewards at VillageMD

Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD's benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.

Equal Opportunity Employer

Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.

Safety Disclaimer

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