Remote Social Work Coordinator - SDOH & Care Coordination

Cardiovascular-Associates-of-America; Orlando (FL); Hybrid; USD 55,000 - 75,000; Full time

Job summary

Novocardia, a division of CVAUSA, is seeking a Social Work Coordinator to support a remote multidisciplinary care team in addressing patients' psychosocial needs and social determinants of health. You will assess needs, develop service plans, and connect patients with resources, aligning with care workflows and accreditation standards.

You will coordinate referrals, educate patients and families about available resources, and document interventions in the EHR, ensuring closed-loop referrals and

Qualifications

• BSW degree required.
• Active social work license.
• 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 SDOH assessments and motivational interviewing.
• Meet with patients to discuss social, emotional, environmental, financial, and behavioral health needs.
• Develop and implement personalized care plans coordinating with resources and agencies.
• Educate clients and families about available resources and services.
• Evaluate effectiveness of service plans and conduct follow-up visits.
• Coordinate referrals to internal and external resources and ensure closed-loop processes.
• Facilitate advance care planning discussions and document accordingly.
• Maintain accurate documentation in the EHR and care management platforms.

Skills

Assessment & Counseling

Communication skills

Team collaboration

EHR proficiency

Microsoft Office

Confidentiality & professionalism

Education

BSW degree

Active social work license

Tools

EHR systems

Care management platforms

Job description

Novocardia, a division of CVAUSA, is seeking a Social Work Coordinator to support a remote multidisciplinary care team in addressing patients' psychosocial needs and social determinants of health. You will assess needs, develop service plans, and connect patients with resources, aligning with care workflows and accreditation standards.

You will coordinate referrals, educate patients and families about available resources, and document interventions in the EHR, ensuring closed-loop referrals and