Social Work Coordinator

ABOUT: Novocardia, a division of CVAUSA, is on a mission to revolutionize cardiovascular care and empower clinicians across the United States to consistently deliver high-quality, prevention-focused, value-based, patient-centered care. Chronic disease is the dominant cause of avoidable healthcare spending and death in the United States and worldwide. Fortunately, much of this disease burden and associated spending is potentially avoidable through delivery of more proactive, prevention-focused care. We are deeply passionate about improving care quality, and providing more Americans with access to great, evidence-based chronic disease care. We are looking for high integrity, mission-oriented people who are passionate about improving the quality and value of chronic disease in America, excited to join a dynamic, rapidly growing, and diverse team.Position Summary The Social Work Coordinator plays a critical role in supporting Novocardia’s remote, multidisciplinary care team by addressing patients’ psychosocial needs and social determinants of health (SDOH) that require intervention. This role partners closely with Registered Nurses and Medical Assistants to ensure non-clinical barriers to care are identified, addressed, and integrated into the patient’s overall care plan. The Social Work Coordinator is responsible for responsible for overseeing and coordinating social services for individuals in need. This role involves assessing client needs, developing service plans, and connecting clients with appropriate resources and support systems. This role ensures timely documentation, closed-loop referrals, and alignment with program workflows, quality standards, and accreditation requirements. Job Responsibilities SDOH Assessment & Patient Support

• 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

Care Coordination & Resource Referral

• 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.

Advance Care Planning & Patient Education

• 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.

Documentation, Quality & Compliance

• 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.

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.

Skills & Competencies

• Strong assessment, counseling, and communication skills.
• Comfort conducting advance directive and goals-of-care discussions with patients and families.
• Knowledge of community resources, benefits, and social service systems.
• Ability to work collaboratively within a remote, multidisciplinary care team.
• Strong organizational skills with the ability to manage multiple patient needs and follow-up activities.
• Proficiency with EHRs, care management platforms, and Microsoft Office tools.
• Ability to maintain professionalism, confidentiality, and empathy in sensitive situations.

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