Social Worker – Burlington

Do you want to make a difference in healthcare?

Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community.  Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.

Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients at no incremental financial cost to them. We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.

Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group.

At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.

The primary role of the Social Worker (SW) is to assess the psychosocial needs of members and provide solution-focused care coordination to address issues that impede their ability to adhere to their medical care plan.  The SW is an active member of the Interdisciplinary care team (IDT). Social work services will be provided in home, telephonically and/ or video.

The Social Worker is responsible for the primary duties listed below.

• Facilitating serious illness / goals of care discussion with the patient and family
• Conducting an assessment of the patient’s and family’s strengths and needs; this may be done in the home, telephonically and or video
• Developing collaborative care plan goals with the patient and family and/ or caregivers and IDT members
• Connecting patient and/ or patient’s family/ caregiver to appropriate community resources and supports
• Providing solution focused case management
• Providing brief therapeutic interventions to patient and family
• Utilizing motivational interviewing (MI) and other psychotherapeutic techniques to elicit behavior change
• Promoting patient and family self-management strategies
• Enhancing connectivity between patients and members of the interdisciplinary team
• Navigating community resources and developing community partnerships to improve access to care and ease of systems navigation

• Master’s Degree (MSW) in Social Work
• Meet all state certification and licensing requirements
• Minimum of three (3) years of social work experience (internship not included)
• Minimum of two (2) years of social work experience in a healthcare setting
• Experience in delivering home-care or field case management is preferred
• Excellent communication skills and knowledge of accessing community resources
• Access to reliable transportation to conduct patient visits required; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy

In order to work with potentially vulnerable patient populations and to keep employees healthy while caring for patients, all patient-facing employees of Landmark must provide evidence of the following required immunizations/vaccinations as a condition of employment: TB, MMR, Tdap, and Influenza. Declinations may be accommodated based on your medical history, an allergy or religious beliefs. Please immediately contact HR if you wish to apply for an exemption from our vaccination requirements so that we may determine if you qualify for an accommodation.