Social Work Care Manager Village@Home

Join VillageMD as a Social Work Care Manager in Fort Collins, CO

Join the frontlines of today's healthcare transformation

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. 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 he