• Partner with Registered Nurse Case Managers to support members through assessment, care planning, and advocacy • Identify and coordinate community resources related to housing, transportation, financial assistance, safety, and behavioral health needs • Engage members telephonically and electronically to support positive health and lifestyle outcomes • Assist members in overcoming barriers to care and accessing appropriate services • Collaborate with interdisciplinary teams to address medical, psychosocial, and behavioral health needs • Support a diverse member population across all stages of life

• Social Worker works in a collaborative role with all members of the health care team and community service agencies to coordinate care for Sentara Health Plan members to improve health outcomes. • Assesses for barriers to compliance with the medical care plan and implements appropriate interventions to promote improved health and compliance with recommended therapy. • Acts as a resource to assist members in need of community-based program assistance and empowers the member with the skills to navigate the process for obtaining appropriate medical care and community assistance.

• Provides information & helps coordinate access to resources and services for patients • Completes patient forms when necessary • May administer psychosocial needs assessments • Acts as a patient/family advocate in negotiating the health care system • Develops and maintains working relationships with community agencies

• Telephonic and video visits with patients and caregivers • Establish trust and build strong relationships with our patients • Interdisciplinary collaboration with teammates (including clinicians, nurses, and care coordinators) to ensure cohesive, patient-centered care for high-needs patients • Conduct Social Work interventions to maximize the effectiveness of the program • Psychosocial screenings with personalized care plans tailored to patients’ needs • Emotional and caregiver support • Navigate family/caregiver support • Social determinants of health and social drivers of utilization • Behavioral health navigation • Long term care planning • Advanced care planning • Know how to balance multiple competing priorities from patients • Work with family members/caregivers to help them understand the patient’s needs and how to support them • Facilitate and participate in joint visits • Participate in team huddles, panel reviews, interdisciplinary team rounds, and program/role growth and development • Build relationships and coordinate with key local market and internal stakeholders • Document all clinical interactions in the electronic health record