Social Worker

About Our Company We're a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care. Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians. When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care. Job Description We are hiring at Starling Physicians, a VillageMD company. Essential Job functions: In collaboration with the Care Teams, develop and promote standard processes for referral and complex coordination of care. Develop a tracking mechanism and a database that will allow outcomes reporting on source and types of referrals, patient demographics, interventions, required successes, and other relevant variables. Work with providers and all nursing staff to provide ongoing education on the role of the Social Worker and available community resources. Mentor peers to increase knowledge, skills, and productivity of the team. Maintain comprehensive social service resource directory including, but not limited to, entitlements, housing opportunities, counseling and advocacy support, financial and legal resources. Establish working relationships with representatives from community agencies to ensure access to services for patients and caregivers. Researches new community and/or national resources to share with staff and providers, and to remain abreast with current trends and opportunities. Collaborate with providers and clinical teams to initiate contact with high-risk patients (identified by Nurse Care Managers or via MD referral process) and respond to patient's psychosocial needs, which includes: Initial screening: Performs chart review to determine, based on patient's condition(s), level of care needs and potential social service interventions required. Contact patient and/or responsible party to facilitate potential social service intervention(s) to meet goals of care plan. Perform psycho-social assessment and responds to patient/family psychosocial needs by engaging community resources via care plan. Provide supportive counseling and education as needed to facilitate care plan and/or appropriate community resource engagement. Documents contacts, interventions, and care plan updates in patient's EMR. Collaborates with patients' health care team to assure coordination of care and appropriate modifications of treatment plans. Monitor, evaluate and record patient progress according to measurable goals described in treatment plan. Collaborate with external community and social service agencies, as needed, to assure that at-risk patients are maintained in the community with appropriate service delivery. Assist families with end of life planning. Conduct case conferences for development of care plans for target patient populations in collaboration with primary care physician and other care team members and ancillary providers. Initiate and update Care Plans for appropriate patients in close collaboration with PCP, patient and family. Incorporates clinical service team and physician feedback into care management planning. Collaborate with all members of the health care team to include members of the interdisciplinary care team (e.g., Nurse Care Managers, Clinical Pharmacist, Certified Diabetic Educator, Behavioral Health clinicians), the patient and their family members as appropriate. Engage at-risk patients (and their caregivers) in understanding and setting self-management plans in a culturally and linguistically appropriate manner. Support at-risk patients in their health behavior change efforts. Provide ongoing monitoring of patient involvement, participation and compliance with treatment plan, updating Care Plan as needed. Identify and participate in the development of strategies to reduce unnecessary hospitalization or ED/Urgent Care visits (aka resource consumption) and enhance or improve patient satisfaction and safety. Perform all social work activities across the continuum of care while adhering to the core values of patient confidentiality, privacy, safety, advocacy, and adherence to ethical, legal and accreditation/regulatory standards. General Job functions: Other job duties as required. Physical Job Requirements: Pushing and pulling, taking frequency and weight into consideration. Physical agility, which includes ability to maneuver body while in place. Dexterity of hands and fingers. Balance is maintained during climbing, bending and/or reaching Endurance (e.g. continuous typing, prolonged standing/bending, walking). Blood-borne Pathogens: Contact with patients or patient specimens are possible. Education, Certification, Computer and Training Requirements: Master's level Social Work degree or equivalent Master's degree required. Valid Social Worker License in the state of CT Minimum 3 years' experience required. Case management certification preferred. Program planning experience is highly desired. Demonstrate ability to use the EHR and care management registries/databases to effectively communicate, document and evaluate social work goals. Proficient in Microsoft Office suite required. Maintain core proficiencies and competencies as defined by the Social Work/Care Management Program. Continually seek new knowledge and learning regarding comprehensive care management principles. Strong Communication and interpersonal skills required. Travel: Ability to travel between offices of Starling Physicians, for meetings and to meet with patients at various locations required. About Our Commitment Total Rewards at VillageMD Our team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD's benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan. Equal Opportunity Employer Our Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws. Safety Disclaimer Our Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, or file a complaint at