Social Worker Field Care Coordinator - Care at Home - DC, MD, VA

UnitedHealth Group•Columbia, MD

5d•$60,200 - $107,400•Onsite

About The Position

Optum Home & Community Care is seeking a Social Worker Field Care Coordinator for its Care at Home program. The program coordinates clinical care for members in their residences through an integrated, longitudinal model. In collaboration with an interdisciplinary care team—including clinicians, primary care providers, other providers, and professionals—the coordinator helps members navigate the health care system and connect with support services. The role serves members in DC, Maryland, or Virginia and is field-based in the greater Washington, D.C. area, with approximately 50–75% of work time spent visiting members in their homes or local long-term care facilities. The position requires flexibility, adaptability, and patience. The coordinator develops individualized care plans, connects members with health and community resources, advocates for members and families, and coordinates services across the continuum of care. The role includes in-person visits and phone contact, member education and engagement, documentation in electronic health record systems, and collaboration with primary providers and multidisciplinary teams. Standard hours are Monday through Friday during normal daytime business hours; no on-call work, weekends, or holidays are required.

Requirements

Master’s degree in social work or another related clinical field.
Active and unrestricted LICSW or LGSW license in Washington, D.C., or ability to obtain a Washington, D.C. license within 90 days of hire.
At least 2 years of experience in long-term care, home health, hospice, public health, or assisted living.
At least 2 years of experience using MS Word, Excel, and Outlook.
At least 1 year of experience using an Electronic Medical Record.
At least 1 year of clinical case management experience.
Valid driver’s license and access to reliable transportation.
Ability to work in a field-based capacity in Washington, D.C.
Reside within 50 miles of Washington, D.C.

Nice To Haves

Certified Case Management (CCM).
At least 1 year of experience working with the geriatric population.
At least 1 year of LTSS (Long Term Services and Supports) experience.
Experience arranging community resources.
Field-based work experience visiting member homes.
HCBS (Home and Community Based Services) experience.
Background managing populations with complex medical or behavioral needs.

Responsibilities

Assess, plan, and implement individualized care management interventions directed toward the most appropriate, least restrictive level of care.
Develop and implement care plan interventions across the continuum of care, serving as a single point of contact.
Communicate health-related information with stakeholders to support timely, coordinated, quality care and services.
Advocate for members and families so their needs and choices are represented and supported by the health care team.
Identify interventions and resources to address psychosocial, transportation, long-term care, health care, and socioeconomic needs.
Document care plans in appropriate electronic health record systems and enter required data.
Maintain member engagement by establishing rapport, demonstrating empathy, and building trust.
Collaborate with primary providers and multidisciplinary teams to align goals and coordinate care.
Provide ongoing support for advanced care planning.
Reassess care plans at appropriate intervals, including after significant changes in condition or achievement of goals.
Work effectively within legal and regulatory requirements and use evidence-based guidelines, including medical necessity guidelines and practice standards.
Make outbound calls and receive inbound calls to assess members’ current health status.
Identify gaps or barriers in treatment plans.
Educate members to support self-management and condition understanding.
Make referrals to outside sources and connect members with resources such as home health aides and Meals on Wheels.
Provide ongoing quality care through communication with members in person and by phone.