Population Health Case Manager - Social Work

The Rector & Visitors of the University of Virginia
$21.10 - $42.21 Hourly
vision insurance, paid time off
United States, Virginia, Charlottesville
1215 Lee Street (Show on map)
Sep 04, 2025
The Population Health Case Manager plays a key role in patient progression at UVA Health. Responsibilities include reviewing patient charts, scheduling appointments, calling patients weekly, conducting screenings, and connecting patients with community resources. This role involves interacting with patients telephonically, collaborating with healthcare teams, emergency room and clinical care teams, and external partners. The position delivers comprehensive care coordination, aiming to enhance patient outcomes and elevate the overall quality of healthcare services. Committed to VDH (Virginia Department of Health) standards, they collaborate with healthcare teams for a patient-centered approach, contributing to holistic and efficient healthcare experiences. Review patient medical records. Assist with appointment scheduling and rescheduling. Document work in the medical record. Submit reports on productivity and patient progression. Ensure compliance with hospital and department policies. Coordinate care with health system team members and care teams in the community. Conduct weekly phone calls with patients to review post-discharge plans and address concerns. Prepare patients/families for discharge and engage care team. Assist Population Health clinicians/social workers with care plans. Coordinate with external agencies for service continuity. Enhance quality of patient care and identify ongoing support needs. Review discharge instructions, ensuring patient understanding. Place orders for vital signs monitoring and coordinate with providers. Conduct standardized screenings such as SDOH (Social Determinants of Health), PHQ, and Digital Health Literacy Assist patients with screening documentation for financial assistance. Follow up on referrals for appointments, DME, and home health services. In addition to the above job responsibilities, other duties may be assigned. MINIMUM REQUIREMENTS Education: Bachelor's Degree preferred. In lieu of degree 1-3 years of relevant experience may be considered. Experience: 1 year of experience in a clinical environment is preferred. Licensure: None. PHYSICAL DEMANDS This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs. Position Compensation Range: $21.10 - $42.21 Hourly Benefits Comprehensive Benefits Package: Medical, Dental, and Vision Insurance Paid Time Off, Long-term and Short-term Disability, Retirement Savings Health Saving Plans, and Flexible Spending Accounts Certification and education support Generous Paid Time Off UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center. 2023-2024 U.S. News & World Report "Best Hospitals" guide rates UVA Health University Medical Center as "High Performing" in 5 adult specialties and 14 conditions/procedures. We are one of 70 National Cancer Institute designated cancer centers. UVA Health Children's is named by 2023-2024 U.S. News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation. Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond.