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The Social Worker II plays a vital role in delivering compassionate, patient‑centered care within the Ryan White HIV Care Program. This position provides comprehensive social work services, medical case management, and care coordination to individuals living with HIV and their families. Working closely with a multidisciplinary healthcare team, the Social Worker II helps patients navigate complex medical and social systems, reduce barriers to care, and achieve improved health outcomes across the continuum of care.
Job Responsibility:
Identify patients who would benefit from medical case management services through initial screening and ongoing assessment
Conduct comprehensive biopsychosocial assessments by interviewing patients and families and evaluating clinical and social determinants of health
Develop, implement, and regularly reassess individualized care plans and acuity scores in accordance with Ryan White program policies and requirements
Provide continuous monitoring of patient progress toward treatment goals and adjust care plans as needed
Initiate and coordinate appropriate internal and external referrals to address medical, psychosocial, financial, and community support needs
Facilitate access to healthcare coverage and medications by collaborating with Patient Navigators and assisting with enrollment in the Healthcare Marketplace, HMAP, co‑payment assistance, patient assistance, and 340B programs
Collaborate with Patient Navigators, Triage Nurses, and Disease Intervention Specialist Bridge Counselors to support patients who are lost to care and promote re‑engagement using evidence‑based treatment and prevention strategies
Advocate on behalf of patients to address unmet needs and reduce barriers to effective care
Participate actively in weekly multidisciplinary team meetings, clinical conferences, staff meetings, and assigned committees or task forces
Collaborate with the care team to develop and implement discharge plans that support patient progression through the continuum of care
Maintain current knowledge of federal, state, and local regulations, payer requirements, and reimbursement practices that impact patient care
Coordinate patient and family care conferences as needed
Identify barriers to efficient and effective care delivery and proactively seek strategies to resolve them
Complete all required HIV certification and medical case management training as mandated by the NC HIV Care Program
Document all assessments, interventions, and care coordination activities accurately and timely in the electronic medical record in accordance with departmental standards
Demonstrate professionalism, adaptability, and the ability to work effectively in a fast‑paced healthcare environment with frequent interruptions
Travels as needed to community agencies (e.g., Department of Social Services and other partner organizations) to support care coordination, advocacy, and access to services
Requirements:
Master’s degree in Social Work (MSW) from a Council on Social Work Education (CSWE)–accredited program preferred
Consideration will be given to candidates with a master’s degree in a health services–related field or a bachelor’s degree in social work with relevant experience
Social work and/or medical case management experience in a healthcare setting is desirable
Demonstrated ability to provide age‑ and developmentally appropriate care and to work collaboratively within an interdisciplinary team
What we offer:
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Opportunity for annual increases based on performance