Population Health Case Manager - Social Work

• Review patient medical records.
• Assist with appointment scheduling and rescheduling.
• Document work in the medical record.
• Submit reports on productivity and patient progression.
• Ensure compliance with hospital and department policies.
• Coordinate care with health system team members and care teams in the community.
• Conduct weekly phone calls with patients to review post-discharge plans and address concerns.
• Prepare patients/families for discharge and engage care team.
• Assist Population Health clinicians/social workers with care plans.
• Coordinate with external agencies for service continuity.
• Enhance quality of patient care and identify ongoing support needs.
• Review discharge instructions, ensuring patient understanding.
• Place orders for vital signs monitoring and coordinate with providers.
• Conduct standardized screenings such as SDOH (Social Determinants of Health), PHQ, and Digital Health Literacy
• Assist patients with screening documentation for financial assistance.
• Follow up on referrals for appointments, DME, and home health services.
• In addition to the above job responsibilities, other duties may be assigned.

MINIMUM REQUIREMENTS

Education: Bachelor's Degree preferred. In lieu of degree 1-3 years of relevant experience may be considered.

Experience: 1 year of experience in a clinical environment is preferred.

Licensure: None.

PHYSICAL DEMANDS
This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.

The University of Virginia is an equal opportunity employer. All interested persons are encouraged to apply, including veterans and individuals with disabilities. Click here to read more about UVA's commitment to non-discrimination and equal opportunity employment.