Provides care that is inclusive and respectful of socioeconomic status, race, ethnicity, age, mental or physical disability, religion, gender, sexual orientation, or national origin.
Builds open, trusting, respectful relationships with diverse patients and families both remotely and in person.
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social factors which impact optimal health.
Anticipates and responds to patient and family needs.
Problem-solves unique barriers to communication and care.
Communicates effectively with diverse audiences both orally and in writing.
Works with interdisciplinary teams to improve patient, family, and community outcomes.
Electronically documents care according to industry and institutional standards.
Performs other duties as assigned.
The job includes the following essential functions:
Program development and refinement in support of the Fortify Children’s Health mission and Fortify Cares priorities.
Comprehensive and continuous assessment of patient and family including medical, social, educational and personal history.
Identification of and access to community resources to optimize effective and efficient care outcomes in collaboration with the multidisciplinary team.
Advocating for patients and family members in conjunction with the healthcare team and Fortify team members.
Patient-centered care planning that results in development, implementation, and ongoing evaluation of an individualized plan of care that is agreed-upon by the patient and family and communicated between care providers while ensuring patients and family members are actively informed of and participating in the care process in conjunction with the care team members.
Ability to document and communicate in compliance with HIPAA and other regulatory guidelines.
Education and support for patients and caregivers.
Ongoing Identification and Referral to appropriate community resources based on assessment of needs.
Consistent documentation that meets care, regulatory and accreditation requirements.
Education: Bachelor's degree or graduate of an accredited Registered Nursing program
Experience: 2 years of relevant care management experience, CCM preferred. Strong understanding of Care Coordination best practices. Proficient computer skills. Strong organizational skills and the ability to work independently. Excellent communication skills and the ability to interact with diverse individuals. Bilingual (English/Spanish) preferred. Preferential consideration given for experience working with children, community partners or in a behavioral health setting. Prior work with Medicaid population a plus. Experience conducting medication reconciliation with patients and identifying discrepancies. Experience communicating with medical providers regarding patient needs. Comfort working in a fast pace and dynamic “startup” environment.
Licensure: Licensed Clinical Social Worker or Registered Nurse with current, unrestricted Virginia license.
Work will involve intermittent travel to professional locations to meet with provider teams and/or patients and families. Work includes extended periods of sedentary activity including talking on the telephone and using the computer.
COVID Vaccination Requirement and Guidelines
Please visit the UVA COVID-19 Job Requirements and Guidelines webpage prior to applying for current information regarding vaccination requirements and guidelines for employment at UVA.
The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.