Social Worker Care Coordination - Population Health

**Summary of Primary Function/General Purpose of Position**

In the capacity of a Social Worker, provide clinical care management services to identified eligible patients, coordinating care to obtain desired health outcomes, improve self-care abilities, and decrease unnecessary cost of care. Work as a member of Interdisciplinary Team (IDT) along with the Ambulatory Care Manager (ACM) and Care Coordinator to ensure the assigned patient’s individual needs are identified and addressed in a timely manner. Perform standardized comprehensive needs assessment, identifying and addressing barriers to care and aligning patients with available benefits and resources.

***This is a remote/work from home position, primarily supporting our Hampton Roads, VA market. Hire **does not have to be living in the area, but will need to be familiar with the region and community resources.**

**Essential Job Functions**

+ Maintain a caseload of patients according to departmen...