Social Work Case Manager

Job Description

A bit about this role: 

Devoted Medical Group was founded on the belief that if we treat each member like we would our loved ones, we can meaningfully improve healthcare experiences and outcomes for some of America’s most vulnerable patient populations. The Complex Care Department is at the heart of this goal: we are a highly collaborative, multidisciplinary team of physicians, nurse practitioners, case managers, social work case managers, community health workers, and outreach coordinators united by our mission to build a better care delivery system for Devoted’s most complex members.  We provide whole-person clinical, social and logistical support for patients with complex chronic conditions, frail elders, and patients at high risk of hospital admissions.

As a Social Work Case Manager, you will support the care team in serving our patients and assist with care plans that promote patient well-being by coordinating services to address socioeconomic and psychosocial needs. This will involve supporting the development of care plans that align with community, clinical, and financial resources while providing coaching and support to patients and their caregivers.   Additionally you will support the improvement of coping skills, self-management, and caregiver assistance; and facilitate advanced care planning discussions, including palliative or hospice care transitions when appropriate.  You will examine, challenge, and seek to expand how the community environment supports the patient’ needs, and work closely with other members of the multidisciplinary team.

Responsibilities will include: 

• Establish trust and build strong relationships with our patients telephonically and virtually

• Interdisciplinary collaboration with the interdisciplinary team (including clinicians, case managers, community health workers, and coordinators) to ensure cohesive, patient-centered care for high-needs patients

• Engage with  patients to identify social barriers to assist in resource alignment, & coordination services to maximize the effectiveness of the Complex Care Department:

  • Conduct screenings and create personalized action plans tailored to patient’s needs 

  • Recognize caregivers who exhibit signs of burnout or are actively coordinating the patient's care, providing emotional support and additional resources when needed 

  • Assist in navigating complex family/support issues

  • Facilitate conversations about end-of-life planning 

  • Collaborate with patients to identify their long-term care planning needs and goals. Provide information on available options and support in arranging referrals and coordinating necessary care

  • Coordinate care between the Devoted Medical Behavioral Health Team and monitor outcomes

• Know how to balance multiple competing priorities for complex patients

• Build relationships and coordinate with key local market and internal stakeholders 

Attributes to success: 

• You’re a caring problem solver who can break down barriers 

• You connect with people quickly 

• You can prioritize needs against multiple competing demands

• You follow up relentlessly 

• You have comfort in the weeds of logistics 

• A deep caring to make a change in the healthcare experience: you love to serve and make a difference 

• The ability to adjust your tone and approach to different people 

• You can articulate and break down complex information for an interdisciplinary team to be able to coalesce around a plan of care

• Are present, reliable and timely for our patients and the team 

• The ability to work in a changing environment: which means moving quickly and being transparent in your work, what’s going well, what’s not 

Desired skills and experience: 

• Ability to work in a fast-paced environment 

• Embrace, crave and be comfortable with new and ever-changing technologies

• Have a minimum of 3 years working in medical social work, case management, or care coordination

• Master’s degree in social work and active state license

• Bilingual in Spanish preferred 

• Health insura