Social Worker Field Care Coordinator

Responsibilities

• Assess, plan, and implement individualized care management interventions for members in their homes or long-term care facilities
• Develop and implement care plans throughout the continuum of care as a single point of contact
• Advocate for members and families to ensure their needs and choices are supported by the healthcare team
• Identify psychosocial, transportation, and long-term care resource gaps to meet specific consumer needs
• Document care plans and member data accurately within Electronic Health Record (EHR) systems
• Collaborate with primary providers and multidisciplinary teams to align care goals
• Provide member education to assist with self-management and connect them to community resources like Home Health Aides or Meals on Wheels
• Conduct outbound and inbound calls to assess current health status and identify barriers to treatment

Requirements

• Master's degree in social work or a related clinical field
• Active and unrestricted LICSW or LGSW license in Washington D.C. (or ability to obtain within 90 days of hire)
• 2+ years of experience in long-term care, home health, hospice, public health, or assisted living
• 2+ years of experience with MS Office (Word, Excel, and Outlook)
• 1+ years of experience using Electronic Medical Records (EMR)
• 1+ years of clinical case management experience
• Valid Driver's License and access to reliable transportation
• Ability to work in a field-based capacity (50-75% travel within the local area)
• Residency within 50 miles of Washington, D.C.

Preferred Qualifications

• Certified Case Management (CCM) credential
• 1+ years of experience working with the geriatric population
• 1+ years of experience with Long Term Services and Supports (LTSS)
• Experience arranging community resources or working with Home and Community Based Services (HCBS)
• Experience in field-based work involving home visits
• Background in managing populations with complex medical or behavioral needs

Benefits

• Comprehensive health plans and coverage for you and your loved ones
• Financial benefits including 401k contributions and equity stock purchase programs
• Incentive and recognition programs
• Resources for emotional well-being and stress management

About the Company

Optum Home & Community Care, part of the Optum family of businesses, is creating an integrated care model that holistically addresses an individual's physical, mental, and social needs. We help patients navigate the healthcare system and connect them to key support services to help them stay well at home.