Social Worker II, Ryan White Care Program

Advocate Health and Hospitals Corporation • Wake Forest, NC

3d • $31 - $46

About The Position

The Social Worker II plays a vital role in delivering compassionate, patient‑centered care within the Ryan White HIV Care Program. This position provides comprehensive social work services, medical case management, and care coordination to individuals living with HIV and their families. Working closely with a multidisciplinary healthcare team, the Social Worker II helps patients navigate complex medical and social systems, reduce barriers to care, and achieve improved health outcomes across the continuum of care.

Requirements

• Master’s degree in Social Work (MSW) from a Council on Social Work Education (CSWE)–accredited program preferred.
• Consideration will be given to candidates with a master’s degree in a health services–related field or a bachelor’s degree in social work with relevant experience.
• Social work and/or medical case management experience in a healthcare setting is desirable.
• Demonstrated ability to provide age‑ and developmentally appropriate care and to work collaboratively within an interdisciplinary team.

Responsibilities

• Identify patients who would benefit from medical case management services through initial screening and ongoing assessment.
• Conduct comprehensive biopsychosocial assessments by interviewing patients and families and evaluating clinical and social determinants of health.
• Develop, implement, and regularly reassess individualized care plans and acuity scores in accordance with Ryan White program policies and requirements.
• Provide continuous monitoring of patient progress toward treatment goals and adjust care plans as needed.
• Initiate and coordinate appropriate internal and external referrals to address medical, psychosocial, financial, and community support needs.
• Facilitate access to healthcare coverage and medications by collaborating with Patient Navigators and assisting with enrollment in the Healthcare Marketplace, HMAP, co‑payment assistance, patient assistance, and 340B programs.
• Collaborate with Patient Navigators, Triage Nurses, and Disease Intervention Specialist Bridge Counselors to support patients who are lost to care and promote re‑engagement using evidence-based treatment and prevention strategies.
• Advocate on behalf of patients to address unmet needs and reduce barriers to effective care.
• Participate actively in weekly multidisciplinary team meetings, clinical conferences, staff meetings, and assigned committees or task forces.
• Collaborate with the care team to develop and implement discharge plans that support patient progression through the continuum of care.
• Maintain current knowledge of federal, state, and local regulations, payer requirements, and reimbursement practices that impact patient care.
• Coordinate patient and family care conferences as needed.
• Identify barriers to efficient and effective care delivery and proactively seek strategies to resolve them.
• Complete all required HIV certification and medical case management training as mandated by the NC HIV Care Program.
• Document all assessments, interventions, and care coordination activities accurately and timely in the electronic medical record in accordance with departmental standards.
• Demonstrate professionalism, adaptability, and the ability to work effectively in a fast‑paced healthcare environment with frequent interruptions.
• Travels as needed to community agencies (e.g., Department of Social Services and other partner organizations) to support care coordination, advocacy, and access to services.

Benefits

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

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