Full Time Remote Social Worker for our AIM (Advanced Illness Management) Program to join our team covering Augusta, GA. This person will work with patients, their families, PCP, AIM, and other health care professionals to recognize and understand the social/mental stress and/or disorder that magnifies the symptoms related to the serious illness and support/educate patients/families in understanding and executing advance care plan documents that are consistent with their wishes.

Provides telephonic and as needed in-home assessments of members’ medical, psychosocial, physical and spiritual needs. Develops, implements, and monitors person centered service plan, and ensures continuity of care across all healthcare settings by collaborating with the interdisciplinary team, PCP, member/member’s representatives, and specialists. Educates members on disease processes, preventative health, and quality of life interventions.