VA - License Clinical Social Worker

Ponos Care specializes in providing compassionate value-based care through a physician-driven, home- and mobile-based model. Our comprehensive approach integrates social, mental, physical, and economic solutions, addressing the unique needs of patients with chronic conditions such as sickle cell disease, ulcerative colitis, Crohn's disease, and severe rheumatoid arthritis.

Our mission is to reduce emergency room visits and improve the quality of life for our patients through comprehensive, holistic coordinated care. We provide services currently on a national level.

The Licensed Clinical Social Worker (LCSW) Care Coordinator provides psychosocial support, care coordination, and advocacy for patients enrolled in the Ponos Care program.

The LCSW Care Coordinator plays a critical role in ensuring patients receive holistic care that integrates medical, behavioral, and social support services within the Ponos Care model, delivering patient centered care through a hybrid environment that includes telehealth services and in home patient visits within a 30-mile radius of Richmond, Virginia.

This role works collaboratively with physicians, nurse practitioners, nurses, and other healthcare providers to address behavioral health needs and social determinants of health that impact patient outcomes.

Regulatory & Compliance Oversight: Ensure compliance with federal and state healthcare regulations. Maintain adherence to Virginia social work licensing standards. Ensure patient confidentiality and compliance with HIPAA regulations. Participate in internal audits and quality reviews related to care coordination documentation.

Operational Excellence & Performance Management: Maintain accurate and timely documentation within electronic health record systems. Track patient progress and care coordination outcomes. Support operational improvements that enhance care delivery and patient experience. Ensure care coordination activities align with organizational goals and performance standards.

Team Leadership & Development: Collaborate with physicians, nurse practitioners, nurses, and clinical care teams. Serve as a behavioral health resource for interdisciplinary team members. Promote collaboration and communication across care teams. Support a culture of compassion, accountability, and patient centered care.

Innovation & Growth: Support innovative care coordination models that address social determinants of health. Contribute to program initiatives that improve patient access to community resources. Assist in developing strategies that enhance patient engagement and care outcomes. Participate in initiatives supporting the continued expansion of Ponos Care services.

We are an Equal Opportunity Employer and are committed to fostering an inclusive and diverse workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, gender identity or expression), national origin, age, disability, genetic information, veteran status, or any other protected characteristic in accordance with applicable federal, state, and local laws. We believe inclusion strengthens our organization and enhances our ability to serve members and communities nationwide. We are committed to providing reasonable accommodation for qualified individuals with disabilities throughout the recruitment and employment process.