Population Health Care Manager II, MSW - Hybrid

WakeMed Health & Hospitals • Raleigh, NC

14d • Hybrid

About The Position

The Population Health Care Manager II, MSW partners with providers, care teams, community resources, and patient support systems to coordinate care and improve outcomes for high-risk, medically complex patients across the continuum of care. As part of an interdisciplinary Population Health team, this role provides comprehensive care management and transitions-of-care services to improve health outcomes, close gaps in care, reduce unnecessary utilization, and support positive experiences for patients, families, providers, and care teams.

The role provides care coordination and case management across inpatient, ambulatory, home, and community settings; assesses medical, behavioral health, psychosocial, and social-determinant needs; and develops and monitors individualized, patient-centered care plans. The Care Manager coordinates transitions and connects patients with appropriate healthcare, behavioral health, social, financial, and community resources. The position also supports patients with complex behavioral health concerns, medical conditions, or social barriers; monitors progress and outcomes; and adapts interventions as needs change.

The Care Manager educates, coaches, advocates for, and empowers patients, delegates care-plan responsibilities to appropriate team members, and collaborates with providers, practices, caregivers, community agencies, and patient support networks. Data analytics, population health principles, quality measures, and evidence-based practices inform interventions and improvement opportunities. The role requires accurate, timely documentation and support for high-quality, cost-effective, patient-centered care, while meeting established quality, performance, and patient-outcome goals.

This position offers a flexible hybrid work environment and requires the employee to be within driving distance of the Raleigh campus. WakeMed describes its Population Health team as collaborative, interdisciplinary, and growing, with opportunities to influence processes and lead improvements.

Requirements

• Master of Social Work degree required.
• Licensed Clinical Social Worker Associate or Licensed Clinical Social Worker required.
• Two years of clinical social work experience required.
• Demonstrated expertise in care coordination, case management, population health, and transitions of care.
• Experience managing high-risk, medically complex, behaviorally complex, or socially vulnerable patient populations.
• Strong knowledge of behavioral health needs and social determinants of health.
• Strong assessment, critical-thinking, care-planning, and problem-solving skills.
• Strong organizational, time-management, and documentation abilities.
• Ability to prioritize competing needs, manage multiple cases, and follow care plans through completion.
• Experience delegating responsibilities and supporting care-team members’ success and accountability.
• Clear, compassionate communication skills and ability to build trusting relationships with patients, families, providers, and community partners.
• Collaborative working style and ability to contribute effectively within an interdisciplinary team.
• Commitment to high-quality, cost-effective, patient-centered care and to respect, teamwork, accountability, and the WakeWay to Excellence.
• Must be within driving distance of the Raleigh campus.

Responsibilities

• Provide comprehensive care coordination and case management across inpatient, ambulatory, home, and community settings.
• Complete psychosocial and diagnostic assessments to identify medical, behavioral health, psychosocial, and social determinant of health needs.
• Develop, implement, monitor, and update individualized, patient-centered care plans.
• Coordinate transitions of care and connect patients with appropriate healthcare, behavioral health, social, financial, and community resources.
• Support patients experiencing complex behavioral health concerns, medical conditions, or barriers related to social determinants of health.
• Monitor patient progress, evaluate outcomes, and adjust interventions as needs change.
• Educate, coach, advocate for, and empower patients to strengthen self-management and achieve health goals.
• Delegate care-plan responsibilities to appropriate team members and ensure timely follow-through.
• Collaborate with physicians, advanced practice providers, nurses, social workers, practices, community agencies, caregivers, and patient support networks.
• Use data analytics, population health principles, quality measures, and evidence-based practices to guide interventions and identify improvement opportunities.
• Maintain timely, accurate, and thorough documentation.
• Support providers and practices in delivering high-quality, cost-effective, patient-centered care.
• Meet established quality, performance, and patient-outcome goals.

Benefits

• Flexible hybrid work environment designed to support work-life balance and team collaboration.
• Supportive, team-oriented culture.
• Opportunity to influence processes and lead improvements within a growing Population Health team.
• Purpose-driven work supporting whole-person care and community health.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level