Social Work Care Coordinator - UVA Health : Job Details

UVA Health is seeking a dedicated Social Work Care Coordinator to enhance patient care outcomes by managing complex psychosocial and economic challenges that impede patient progression. This role is pivotal in ensuring patients and their families receive compassionate support while navigating the healthcare system.

The ideal candidate will utilize advanced social work skills to mobilize necessary resources, reducing risks associated with social determinants of health. We are committed to providing respect and understanding to diverse populations through cultural humility.

• Identify patients and families in need of care coordination and community support by reviewing medical records, attending rounds, and responding proactively to patient needs.
• Maintain alignment with practice standards that contribute to the strategic goals of patient progression.
• Collaborate effectively with the RN Case Manager and treatment team to develop safe, timely, and appropriate discharge plans, addressing psychosocial barriers and ensuring compliance with regulations.
• Oversee post-acute discharges for complex cases alongside the Care Management Discharge Manager.
• Facilitate timely patient and family meetings to discuss advance directives, comfort measures, and goals of care.
• Conduct comprehensive psychosocial screenings and lead initiatives to address patients' psychosocial needs, including access to financial resources, legal matters, and necessary referrals.
• Offer referrals for various post-acute services such as LTACH, SNF, IRF, LTC, HH, and DME.
• Uphold ethical principles in all practices, ensuring adherence to NASW and ACMA Case Management standards.
• Organize and lead interdisciplinary rounds, documenting critical discussions and developments.
• Advocate for timely discharge plans that consider the patient's full care needs.
• Engage with community agencies to enhance service delivery and responsiveness.
• Utilize appropriate assessment tools tailored to various age groups during all interactions with clients.
• Collaborate with Risk Management, Patient Relations, and the Ethics Committee to address ethical concerns, applying the NASW Code of Ethics in decision-making.
• Demonstrate flexibility in working within the care management team to ensure all patient needs are met.
• Help patients and families understand their medical conditions, treatment options, and implications of treatment decisions.
• Educate hospital staff regarding the psychosocial needs of patients.
• Other duties may be assigned as needed.

Position Compensation Range: $54,558.40 - $87,297.60 Annual

Minimum Requirements:

• Education: Master's of Social Work required.
• Experience: A minimum of one year of experience in discharge planning within acute or subacute settings.
• Licensure: LMSW/LCSW preferred; ACMA certification is a plus.

Physical Demands:

This position requires standing for extended periods, frequent walking, and bending/stooping. The successful candidate should have strong communicative, auditory, and visual skills; attention to detail; and the ability to write legibly. Ability to lift/push/pull 20-50 lbs may be necessary, with possible exposure to chemicals, blood/body fluids, and infectious diseases.

The University of Virginia is an equal opportunity employer. All interested individuals, including veterans and individuals with disabilities, are encouraged to apply.