Remote Social Work Coordinator for SDOH & Care Access

Cardiovascular Associates of America; Orlando (FL); On-site; USD 52,000 - 70,000; Full time

Job summary

Novocardia, a division of CVAUSA, seeks a Social Work Coordinator to support its remote, multidisciplinary care team from Orlando, FL. The role focuses on addressing psychosocial needs and SDOH within patient-centered chronic care management.

You will assess needs, develop care plans, coordinate resources, and ensure documentation aligns with standards while collaborating with nurses and medical assistants to remove non-clinical barriers to care.

Qualifications

• Bachelor’s degree in Social Work (BSW) required.
• Active social work license.
• Minimum of 2–5 years of experience in healthcare, care management, care coordination, or community-based social work.
• Experience addressing SDOH in chronic care, value-based care, or population health settings preferred.

Responsibilities

• Assess the needs of patients through motivational interviewing and SDOH assessments to determine the appropriate resources to impact care outcomes.
• Meet with patients to discuss identified social, emotional, environmental, financial, and behavioral health needs.
• Develop and implement personalized care plans for clients, coordinating with other professional resources and agencies as needed.
• Educate clients and their families about available resources and services
• Evaluate the effectiveness of service plans and adjust as needed
• Conduct follow-up visits and reassessments to ensure client needs are being met
• Coordinate referrals to internal and external community resources, including behavioral health services, financial assistance, transportation, housing support, food access, and social services.
• Maintain a working knowledge of local, regional, and national resources available to patients.
• Ensure closed-loop referral processes, confirming patients are connected to appropriate services.
• Collaborate with clinical team members to integrate social interventions into the patient’s care plan.
• Facilitate conversations related to advance care planning, including advanced directives, healthcare proxies, and goals of care.
• Ensure documentation of advance care planning discussions aligns with clinical workflows and organizational standards.
• Maintain accurate, timely documentation of assessments, interventions, referrals, and patient interactions in the EHR and care management platforms.
• Ensure documentation and workflows align with organizational policies, quality standards, and accreditation requirements.
• Support audits, reporting, and continuous quality improvement initiatives related to care coordination and SDOH interventions.

Skills

Assessment skills

Counseling

Communication

Community resources knowledge

Remote collaboration

EHR proficiency

Confidentiality

Education

BSW degree

Licensed social worker

Tools

EHR systems

Care management platforms

Microsoft Office

Job description

Novocardia, a division of CVAUSA, seeks a Social Work Coordinator to support its remote, multidisciplinary care team from Orlando, FL. The role focuses on addressing psychosocial needs and SDOH within patient-centered chronic care management.

You will assess needs, develop care plans, coordinate resources, and ensure documentation aligns with standards while collaborating with nurses and medical assistants to remove non-clinical barriers to care.