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Bilingual Social Worker (Spanish)

Company: VillageMD
Location: South Houston
Posted on: July 15, 2019

Job Description:

After decades of high quality primary care delivered in Houston, in 2013 Village Family Practice (VFP) partnered with VillageMD, a new value-based primary care organization. Together, we are committed to helping patients achieve even greater health by delivering the most effective, accessible, and efficient healthcare in the world. By working with patients, clinicians, payers, and other healthcare delivery companies, we're focused on optimizing relationships, capturing data across the healthcare continuum, and surfacing insights within clinical, administrative and financial workflows so physicians and operators can make the best decisions possible. Called VillageMD Houston (VMDH), the organization provides the tools, technology, operations and teams needed to drive the highest quality clinical results across a population.

As an extension of the primary care physician's (PCP) care team, the Social Worker is responsible for providing a variety of services targeting patients identified as high-risk and/or those who are experiencing barriers to meeting their healthcare goals. Principle Social Work services include, but are not limited to, performing comprehensive assessments, developing patient-centered care plans, and providing episodic and longitudinal care planning. Integral to our Care Management team, the Social Worker will be responsible for addressing Social Determinants of Health (SDOH), addressing the behavioral health needs of patients and families and for monitoring behavior modification in high risk patients through empowerment and teaching of self-management skills. As a member of our team, you'll work closely with our care team to connect the dots of collaborative patient care.

What are some unique responsibilities that you'll have at VillageMD?


  • Travel 4-5 days per week locally to facilitate care in patient homes and other facility settings
  • Actively engage and collaborate with PCP's and office staff in identifying high-risk patients
  • Employ motivational interviewing skills to elicit optimal member engagement/outcome
  • Perform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriers in a variety of settings to include but not limited to: patient's homes, PCP clinic and acute & post-acute facilities
  • Communicate assessment findings, care plan goals, interventions and outcomes to PCP, patients and caregivers in a timely manner
  • Provides therapeutic brief intervention to identified at risk patients and assess whether ongoing therapeutic intervention is indicated connecting to long term therapy services as identified



    • Anxiety & Depression
    • Adjustment and grief counseling
    • Change in mental status, unstable or new diagnosis
    • Substance abuse/dependency



    • Collaborates and refers to local community organizations for ongoing behavioral health support

      What you might do in your first year:


      • Maintain a working knowledge of community resources/agencies to address a wide variety of psychosocial needs members may experience
      • Utilize behavioral health screening assessments, identify symptoms of behavioral health and substance abuse concerns, and effectively make referrals to appropriate community resources
      • Effectively support patients, families and caregivers in managing psychosocial barriers
      • Document clinical interventions in applicable care management software systems
      • Develop and maintain effective professional working relationships with assigned PCP practice(s)
      • Provide education and social work services to patients and families related to behavioral health (MH & SA), community resources, and complex case management. Provides patients and families with long term care planning to include Advance Care Planning (Advance Directives, Medical POA, DNR, etc.) Palliative and Hospice care education and referrals

        The following experience is relevant to us:


        • Master's degree in social work with licensure in the state of Texas
        • Licensed Clinical Social Worker Preferred
        • 3 years of experience in a managed/accountable healthcare
        • Experience in a behavioral health setting
        • Expertise in utilizing brief-intervention models of therapy
        • Understanding of the influence behavioral health conditions play in chronic condition management
        • Experience assisting patients through transitions in the care continuum
        • Experience managing psychosocial challenges with patients and families
        • Knowledge of case management and local community resources/agencies and ability to collaborate to effectively manage patients.
        • Skilled in Motivational Interviewing
        • Perform intermediate level of competence with various computer software applications including, MS Outlook, Word, Excel and Power Point
        • Strong verbal and written communication skills
        • Strong interpersonal skills
        • Reliable and insured vehicle and unrestricted driver's license

          At VillageMD, we see diversity and inclusion as a source of strength in transforming healthcare. We believe building trust and innovation are best achieved through diverse perspectives. To us, acceptance and respect are rooted in an understanding that people do not experience things in the same way, including our healthcare system. Individuals seeking employment at VillageMD are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.

Keywords: VillageMD, Houston , Bilingual Social Worker (Spanish), Other , South Houston, Texas

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