Population Health Care Manager II, MSW - Hybrid

Overview

Join Wake Med's Population Health team and make a meaningful impact on the lives of high-risk, medically complex patients. The Population Health Care Manager II, MSW partners with providers, care teams, community resources, and patient support systems to coordinate care, improve outcomes, and support patients across the continuum of care.

As a Population Health Care Manager II, MSW, you will help high-risk and medically complex patients navigate their care with confidence. Working as part of an interdisciplinary Population Health team, you will provide comprehensive care management and transition‑of‑care services that improve health outcomes, close gaps in care, reduce unnecessary utilization, and create a positive experience for patients, families, providers, and care teams.

In this role, you will:

• 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 their health goals.
• Delegate care plan responsibilities to appropriate team members and ensure timely follow‑through.
• Collaborate closely 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 opportunities for improvement.
• Maintain timely, accurate, and thorough documentation.
• Support providers and practices in delivering high‑quality, cost‑effective, and patient‑centered care.
• Consistently meet established quality, performance, and patient outcome goals.

We are looking for an experienced and compassionate social work professional who brings strong clinical judgment, healthcare leadership, organization, and accountability to every patient interaction.

The ideal candidate will have:

• A Master of Social Work degree and applicable professional licensure.
• 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.
• Excellent assessment, critical‑thinking, care‑planning, and problem‑solving skills.
• Strong organizational, time‑management, and documentation abilities.
• The ability to prioritize competing needs, manage multiple cases, and consistently follow care plans through completion.
• Experience delegating responsibilities and supporting the success and accountability of care team members.
• Clear and compassionate communication skills with the ability to build trusting relationships with patients, families, providers, and community partners.
• A collaborative working style and the ability to contribute effectively within an interdisciplinary team.
• A commitment to delivering high‑quality, cost‑effective, and patient‑centered care while demonstrating respect, teamwork, accountability, and the Wake Way to Excellence.