New

Social Worker - Hospital at Home & Continuum Integration- Days

Virginia Commonwealth University Health Systems
United States, Virginia, Richmond
Feb 21, 2026
$10,000 Sign On Bonus for offers accepted by February 28, 2026. Terms and Conditions apply VCU Health is seeking authentic, passionate and inspiring candidates for our virtually enabled Hospital-at Home and Remote Patient Monitoring programs. Housed in the health system's Continuum Integration Center in north Richmond, this exciting opportunity offers innovation, professional growth, and opportunity to be a part of an already incredible team. While the care provided is done virtually or telephonically, the role is on-site in an office environment. The social work position supports the continued growth and development of a robust VCU Health at Home strategy. This include acute virtual care and discharge planning of individuals enrolled in the Hospital at Home program and post-acute virtual care for those in the transitional remote patient monitoring program and transitional telehealth clinic. Hospital at Home and Remote Patient Monitoring programs are gaining momentum nationwide, because of the benefits for patients and health systems, including increased patient satisfaction, improved patient outcomes, better performance on value-based metrics and relieving facility capacity constraints. The model operates with a patient-centric focus and a comprehensive, team-based, outcomes-motivated approach to care using population health principles to keep patients healthy. The focus of the position is: To ensure quality coordination of care for both acute and post-acute patients throughout the VCU Health System. To ensure quality patient care across the continuum, reduce avoidable readmissions, and improve outcomes for both acute inpatients and the highest risk discharged individuals from VCU Health System. To provide high level social work and case management support through the ability to perform virtual and telephonic assessments to then create a plan, intervene, and/or escalate appropriately using critical thinking skills for both acute care and post-acute care patients. To provide counseling support and/or resources for counseling support as needed to patients and/or their caregiver(s) for mental health, behavioral, or emotional issues. To connect patients and/or their caregiver(s) with social determinants of health resources according to their individual needs. To provide crisis interventions or be a resource for other clinical team members to provide crisis interventions by responding to emergent situations. To ensure quality patient care through a holistic interdisciplinary approach by collaborating with the multi-disciplinary care team including but not limited to nurse navigators and case managers, clinical nurses, providers, other social workers, rehab team, pharmacy, clinic staff, and health system leadership. To participate in daily acute care interdisciplinary rounds and post-acute care huddles reporting out discharge planning status and any barriers, safety concerns, or support needs. May be asked to lead interdisciplinary rounds. To ensure quality patient care through collaboration and teamwork with involvement in unit level initiatives and team meetings. VCU Health is seeking authentic, passionate and inspiring candidates to staff a new, virtually-enabled Hospital-at Home program, housed in the health system's Continuum Integration Center in north Richmond. This exciting opportunity offers innovation and professional growth and you would be joining an already incredible team, which is expanding to provide this new service offering under the highly-regarded VCU Health at Home brand. Located in contemporary offices on Richmond's Northside, this on-site position will support the continued growth and development of a robust VCU Health at Home strategy, including 24/7 acute virtual monitoring of individuals enrolled in the VCUHS Hospital at Home program, transitional remote patient monitoring, and triage support for both high-risk ambulatory and post-discharge patients across VCU Health System Hospitals. The purpose of the Clinical Social Worker (MSW) position is to provide both direct patient care to patients and families and assist in the coordination of team delivered services. The Clinical Social Worker will complete a psychosocial assessment; develop treatment plans that are congruent with the overall health care plan; provide psychosocial intervention; educate patients, their family members, staff and social work students; facilitate compliance with treatment; work with the community to provide needed services; and coordinate discharge planning activities. Licensure, Certification, or Registration Requirements for Hire: Licensed Clinical Social Worker in the State of Virginia preferred Licensure, Certification, or Registration Requirements for continued employment: N/A Experience REQUIRED: CSW Level 2: minimum of one (1) year of clinical social work experience Experience PREFERRED: Clinical social work experience in an acute care setting preferred Education/training REQUIRED: Master of Social Work Degree from a Council on Social Work Education accredited program Education/training PREFERRED: N/A Independent action(s) required: Initiate patient/family intervention based on self-assessment of service need(s). Initiate community/facility referrals based on identified patient/family needs. Initiate consultation with facility staff regarding psychosocial patient/family needs. Contact the appropriate Social Services Department to report suspected abuse/neglect/exploitation cases. Develop intervention plans and related interventions with patients/families/significant others. Initiate education activities with and for facility staff. Contribute to quality improvement activities through self-analysis of services and needs. Participate in service area meetings, training, and patient care conferences. Supervisory responsibilities (if applicable): This position may supervise social work students on a voluntary basis. Depending on unit assignment may supervise other Masters and Doctoral Degree students from other disciplines (e.g. Psychology). Additional position requirements: Depending on the unit assignment, may be required to work alternate schedules, weekends, holidays and take call. Age Specific groups served: As appropriate based on unit assignment Physical Requirements (includes use of assistance devices as appropriate): Physical - Lifting less than 20 lbs. Activities: Prolonged standing, Prolonged sitting, Frequent bending, Walking (distance), Reaching (overhead, extensive, repetitive) Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking Emotional: Fast pace environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change Days EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.