Healthy Equity - Social Worker - Population Health & Case Management

JOB SUMMARY:

Responsible for conducting care management and population health activities, including assessing member needs, coordinating care, and facilitating referrals for behavioral health and substance use services. Monitors member outcomes and provider clinical performance to support quality, effectiveness, and continuity of care.

• Conduct comprehensive psychosocial assessments to identify member needs, barriers to care, health-related social needs, and social determinants of health.
• Evaluate member needs related to housing, food insecurity, transportation, financial strain, behavioral health, caregiver support, safety, health literacy, and access to community resources.
• Develop individualized, person-centered care plans in collaboration with members, caregivers, providers, and the interdisciplinary care team.
• Establish measurable goals and interventions that support improved health outcomes, member engagement, and appropriate utilization of services.
• Connect members to community-based organizations, public assistance programs, behavioral health services, long-term services and supports, and other appropriate resources.
• Collaborate with physicians, nurses, behavioral health specialists, pharmacists, case managers, utilization management staff, and community partners.
• Support transitions of care by assisting members after hospitalizations, emergency department visits, skilled nursing facility stays, or other care transitions.
• Assist members in navigating benefits, covered services, community support, and healthcare systems.
• Participate in population health initiatives designed to improve preventive care, chronic condition management, health equity, and quality outcomes.
• Utilize risk stratification tools, claims data, care gaps, utilization patterns, and referrals to prioritize outreach and interventions.
• Support programs targeting high-risk, high-cost, vulnerable, or underserved populations.
• Contribute to interventions focused on reducing avoidable emergency department visits, hospital readmissions, and gaps in care.
• Document assessments, interventions, care plans, member contacts, referrals, outcomes, and case closure activities accurately and timely in designated systems.
• Maintain compliance with CMS requirements, URAC accreditation standards, HIPAA, privacy and security regulations, and company policies.
• Monitor progress toward member goals and update care plans as needed.
• Participate in quality improvement activities, interdisciplinary case conferences, and performance improvement initiatives.
• Identify trends, barriers, and opportunities to improve population health outcomes and member experience.
• Support programs targeting high-risk, high-cost, vulnerable, or underserved populations.
• Contribute to interventions focused on reducing avoidable emergency department visits, hospital readmissions, and gaps in care.
• Document assessments, interventions, care plans, member contacts, referrals, outcomes, and case closure activities accurately and timely in designated systems.
• Maintain compliance with company policies, privacy and security regulations, HIPAA, CMS requirements, and URAC accreditation standards.
• Monitor progress toward member goals and update care plans as needed.
• Participate in quality improvement activities, interdisciplinary case conferences, and performance improvement initiatives.
• Identify trends, barriers, and opportunities to improve population health outcomes and member experience.
• Conduct provider clinical chart audits and provider trainings as needed.
• Serve as a resource for the team of alternative care options.
• Perform other job-related duties as required or assigned.

• Ability to rapidly and effectively diagnose mental health cases and refer to…