Aco Reach Manager Jobs (NOW HIRING)

Definition:

As a core member of the interdisciplinary care team, the Medical Social Worker (MSW) serves as the primary lead for psychosocial assessment, caregiver engagement, and non-clinical risk mitigation for patients enrolled in ACO REACH, GUIDE, and other value-based care models. The MSW provides longitudinal support to patients and caregivers by identifying social risk factors, supporting caregiver stability, coordinating community-based resources, and partnering with clinical team members to reduce avoidable utilization and improve quality of life.

Responsibilities:

• Conduct comprehensive psychosocial assessments for ACO REACH and GUIDE patients, focusing on social determinants of health, behavioral health needs, caregiver support, and gaps in care.

• Conduct ongoing reassessments as patient condition, caregiver capacity, and disease progression evolve, including identification of safety risks, caregiver strain, and psychosocial factors that may increase utilization or compromise care in the home.

• Develop patient-centered care plans in collaboration with the clinical team (NPs, PCPs, Care Coordinators) to support risk reduction, chronic disease management, and quality metric improvement.

• Ensure care plans are actionable, updated longitudinally, and aligned with patient goals, caregiver capacity, and available community resources.

• Participate in interdisciplinary team meetings to discuss patient status, symptom burden, social needs, and next steps in care.

• Perform proactive outreach to high-risk patients identified through population health tools.

• Engage caregivers proactively as part of outreach activities, particularly for patients at risk of functional decline, behavioral escalation, or avoidable emergency department utilization.

• Support patients, families, and caregivers by providing education to improve patient engagement and functional outcomes.

• Provide longitudinal caregiver education, coaching, and emotional support, including anticipatory guidance regarding disease progression, strategies for managing behavioral symptoms, stress and burnout mitigation, and decision support related to care transitions.

• Provide supportive counseling addressing anticipatory grief, coping with serious illness, stress, caregiver burden, and adjustment to progressive diseases.

• Coordinate referrals to community resources including housing, transportation, food assistance, utilities, mental health services, and caregiver programs.

• Act as a central navigator across medical providers, community-based organizations, and long-term services and supports, including respite care, adult day programs, in-home support services, and financial or legal assistance.

• Coordinate resources related to hospice transition, in-home support services, respite programs, community mental health, caregiver support, and financial assistance.

• Facilitate goals of care conversations and advance care planning (POLST, healthcare proxy).

• Support ongoing goals-of-care discussions in collaboration with clinical team members, recognizing that patient preferences and caregiver readiness may change over time.

• Document psychosocial findings, care plans, interventions, and patient outcomes in accordance with palliative care standards.

• Document caregiver interactions, assessments, interventions, and care coordination activities in a manner that supports quality reporting, utilization management, and compliance with CMS program requirements for GUIDE and other value-based care models.

• Contribute to program outcomes including caregiver stability, reduced avoidable utilization, timely care transitions, and sustained patient engagement. Participate in quality improvement initiatives and workflow refinement related to value-based care performance.

• Perform the Initial Comprehensive GUIDE Assessments in collaboration with the provider and conduct monthly Care Navigator follow-up visits with GUIDE patients and caregivers to assess ongoing needs, caregiver concerns, resource utilization, and changes in condition.

• Submit required GUIDE patient information and documentation through the appropriate CMS portal and track submissions to ensure patients are reviewed and accepted into the GUIDE Model.

• Support growth of the GUIDE Model census by identifying and conducting outreach to patients who may be appropriate for the program, providing education regarding GUIDE services, benefits, caregiver support, and available resources, and assisting eligible patients and caregivers through the enrollment process.

• Conduct community outreach and education to increase awareness of the GUIDE Model and available dementia care services among patients, caregivers, healthcare providers, community organizations, and other potential referral sources.

• Assist eligible GUIDE patients and caregivers with accessing respite care benefits available through the GUIDE Model, including education regarding available respite services, coordination with contracted respite providers, scheduling and facilitating services as appropriate, and monitoring utilization in accordance with CMS GUIDE requirements.

• The Social Worker reports directly to the Director of Clinical Operations.

Required Qualifications / Skills:

1. Master’s degree in social work (MSW)
2. Experience working with Medicare-aged patients, including individuals with serious illness and cognitive impairment such as dementia. 
3. Ability to work independently and as part of a multidisciplinary team
4. Strong ethical standards
5. Excellent communication and interpersonal skills

Preferred Qualifications / Skills:

1. Palliative Care, Home Health, or Hospice experience
2. Experience working in value-based programs (e.g., PACE, Medicare Advantage, ACOs, CMS demonstration models, all-inclusive insurance programs)
3. Experience documenting services in support of quality measurement and/or utilization management