Complex Care Social Work Case Manager

Devoted Health•Waltham, MA

3d•$65,000 - $85,000•Remote

About The Position

Devoted Medical Group’s Complex Care Department is a collaborative, multidisciplinary team serving members with complex chronic conditions, frail elders, and patients at high risk of hospital admission. The team provides whole-person clinical, social, and logistical support. The Social Work Case Manager supports the care team by coordinating services that address patients’ socioeconomic and psychosocial needs and by helping develop care plans aligned with community, clinical, and financial resources. The role includes coaching and supporting patients and caregivers, strengthening coping and self-management, assisting caregivers, and facilitating advanced care planning, including palliative or hospice transitions when appropriate. The case manager also works to understand and expand how community resources support patients’ needs and collaborates closely with the multidisciplinary team. The position builds relationships with patients remotely by phone and virtually, identifies social barriers, and coordinates resources and services for high-needs patients. It includes screening patients, developing individualized action plans, supporting caregivers, helping navigate family and support issues, and coordinating behavioral health and long-term care needs. The role requires balancing competing priorities and collaborating with local-market and internal stakeholders. The role is remote-friendly, and candidates should be comfortable working remotely. The listed salary range is $65,000–$85,000 per year. The company’s total rewards package for full-time employees includes employer-sponsored health, dental, and vision plans with low or no premiums; paid time off; a monthly mobile or internet stipend; stock options; bonus eligibility (with stated exclusions); parental leave; and a 401(k) program.

Requirements

At least 3 years of experience in medical social work, case management, or care coordination.
Master’s degree in social work.
Active state license.
Ability to work in a fast-paced, changing environment.
Comfort with new and evolving technologies.
Proven ability to build relationships with patients and interdisciplinary teams.
Ability to multitask while listening, speaking, evaluating, and writing notes.
Ability to prioritize competing needs, follow up reliably, and communicate complex information clearly to an interdisciplinary team.
Team-oriented, self-reflective approach and a can-do attitude.
Comfort working remotely.

Nice To Haves

Bilingual in Spanish.
Health insurance experience; Medicare Advantage experience is a plus.
Experience working with the senior population.
Caring, solutions-oriented approach to breaking down barriers and helping people.
Ability to connect quickly with people and adapt communication to different individuals.
Comfort with logistical details and persistent follow-up.
Strong commitment to improving healthcare experiences and serving patients.
Reliability and timeliness with patients and the team.
Transparency and adaptability in a changing environment.

Responsibilities

Establish trust and build strong relationships with patients by phone and virtually.
Collaborate with clinicians, case managers, community health workers, and coordinators to provide cohesive, patient-centered care for high-needs patients.
Engage patients to identify social barriers and coordinate resources and services.
Conduct screenings and create personalized action plans tailored to patient needs.
Recognize caregiver burnout or substantial caregiving responsibilities, and provide emotional support and resources as needed.
Assist patients in navigating complex family and support issues.
Facilitate conversations about end-of-life planning.
Work with patients to identify long-term care planning needs and goals; explain available options and support referrals and care coordination.
Coordinate care with the Devoted Medical Behavioral Health Team and monitor outcomes.
Balance multiple competing priorities for complex patients.
Build relationships and coordinate with key local-market and internal stakeholders.
Support care plans that promote patient well-being and align with community, clinical, and financial resources.
Coach and support patients and caregivers, including support for coping skills, self-management, and caregiver assistance.
Facilitate advanced care planning, including palliative or hospice care transitions when appropriate.
Examine how the community environment supports patients’ needs and seek ways to expand that support.