Job Description

Req ID: 32239

Department: Population Health

Work Location: Andrews Center

Location: Raleigh, North Carolina

Employment Type: ['Full Time']

FTE: ['1.00']

Hours of Work: ['Monday-Friday *Hybrid*']

Weekend Requirements: No Weekends

Call Requirements: ['No']

Overview

Join WakeMed's Population Health team and make a meaningful impact on the lives of high-risk, medically complex patients. The Population Health Care Manager II, MSW partners with providers, care teams, community resources, and patient support systems to coordinate care, improve outcomes, and support patients across the continuum of care.

What you’ll do

As a Population Health Care Manager II, MSW, you will help high-risk and medically complex patients navigate their care with confidence. Working as part of an interdisciplinary Population Health team, you will provide comprehensive care management and transition-of-care services that improve health outcomes, close gaps in care, reduce unnecessary utilization, and create a positive experience for patients, families, providers, and care teams.

In this role, you will:

• Provide comprehensive care coordination and case management across inpatient, ambulatory, home, and community settings.
• Complete psychosocial and diagnostic assessments to identify medical, behavioral health, psychosocial, and social determinant of health needs.
• Develop, implement, monitor, and update individualized, patient-centered care plans.
• Coordinate transitions of care and connect patients with appropriate healthcare, behavioral health, social, financial, and community resources.
• Support patients experiencing complex behavioral health concerns, medical conditions, or barriers related to social determinants of health.
• Monitor patient progress, evaluate outcomes, and adjust interventions as needs change.
• Educate, coach, advocate for, and empower patients to strengthen self-management and achieve their health goals.
• Delegate care plan responsibilities to appropriate team members and ensure timely follow-through.
• Collaborate closely with physicians, advanced practice providers, nurses, social workers, practices, community agencies, caregivers, and patient support networks.
• Use data analytics, population health principles, quality measures, and evidence-based practices to guide interventions and identify opportunities for improvement.
• Maintain timely, accurate, and thorough documentation.
• Support providers and practices in delivering high-quality, cost-effective, and patient-centered care.
• Consistently meet established quality, performance, and patient outcome goals.

Who we are looking for

We are looking for an experienced and compassionate social work professional who brings strong clinical judgment, healthcare leadership, organization, and accountability to every patient interaction.

The ideal candidate will have:

• A Master of Social Work degree and applicable professional licensure.
• Demonstrated expertise in care coordination, case management, population health, and transitions of care.
• Experience managing high-risk, medically complex, behaviorally complex, or socially vulnerable patient populations.
• Strong knowledge of behavioral health needs and social determinants of health.
• Excellent assessment, critical-thinking, care-planning, and problem-solving skills.
• Strong organizational, time-management, and documentation abilities.
• The ability to prioritize competing needs, manage multiple cases, and consistently follow care plans through completion.
• Experience delegating responsibilities and supporting the success and accountability of care team members.
• Clear and compassionate communication skills with the ability to build trusting relationships with patients, families, providers, and community partners.
• A collaborative working style and the ability to contribute effectively within an interdisciplinary team.
• A commitment to delivering high-quality, cost-effective, and patient-centered care while demonstrating respect, teamwork, accountability, and the WakeWay to Excellence.

About the team and culture:

• Flexible Hybrid Work Environment – Enjoy a hybrid schedule designed to support work-life balance while maintaining strong team connection and collaboration. Must be within driving distance to Raleigh campus.
• Supportive, Team-Oriented Culture – Join a collaborative environment where leaders and team members work together to share knowledge, solve challenges, and support one another's success.
• Strong Interdisciplinary Partnerships – Work closely with primary care providers, nurses, RN care managers, social workers, and other healthcare professionals to deliver coordinated, patient-centered care.
• Make a Meaningful Impact – Help patients with complex medical, behavioral, and social needs navigate the healthcare system, access critical resources, and achieve better health outcomes.
• Drive Innovation and Growth – Be part of a growing Population Health team with the opportunity to influence processes, lead improvements, and help shape the future of care management services.
• Purpose-Driven Work – Play a key role in advancing whole-person care, reducing barriers to care, and improving the health and well-being of the communities we serve.

Department Description

Serving the community since 1961, WakeMed Health & Hospitals is the leading provider of health services in Wake County. With a mission to improve the health and well-being of our community, we are committed to providing outstanding and compassionate care. For more information, visit www.wakemed.org.

EOE

Licensure

Licensed Clinical Social Worker Associate Or Licensed Clinical Social Worker Required

Education

Master's Degree Social Work Required w/LCSW

Experience

2 Years Clinical - Social Work Required