Holly Thammavongsa
Sterling,VA
Summary
MSW healthcare social worker with 3+ years of hospital case management experience coordinating services for medically complex adults across acute care, post-acute care, and community settings. Experienced in Medicaid LTSS assessments, discharge planning, care coordination, SNF/home health/hospice referrals, DME, benefits navigation, interdisciplinary collaboration, and connecting patients with community-based supports. Skilled in independently managing high-acuity caseloads, conducting comprehensive assessments, documenting in multiple EMR/care-management systems, and coordinating care remotely by phone and video.
Overview
1
1
Certification
9
9
years of professional experience
Work History
Case Management Social Worker
UVA Health Culpeper Medical Center
Culpeper, VA
03.2023 - Current
- Manage a high-acuity caseload across ICU, CCU, emergency department, family birth center, and medical-surgical units, coordinating safe transitions of care for medically and psychosocially complex patients.
- Conduct comprehensive biopsychosocial, discharge-planning, and Medicaid Long-Term Services and Supports (LTSS) assessments to identify functional needs, caregiver supports, social determinants of health, and appropriate post-acute and community-based services.
- Coordinate placement and services including SNF, long-term care, home health, hospice, DME, transportation, dialysis, and community-based resources based on patient needs, eligibility, and preferences.
- Educate patients and families regarding available services, benefits, levels of care, and discharge options while advocating for patient autonomy and safe care planning.
- Collaborate with physicians, nursing, therapy, behavioral health, hospice, skilled nursing facilities, community agencies, insurers, and other stakeholders to resolve barriers to discharge and continuity of care.
- Advocate for patients with complex medical, behavioral, financial, social, and safety needs and connect individuals with appropriate community and supportive services.
- Assist patients with Medicaid/LTSS processes, benefit navigation, community resource referrals, and access to supportive services for ongoing care in the least restrictive setting.
- Maintain timely case documentation and daily follow-up using Epic, Meditech, WellSky/CarePort, telephone, and electronic communication.
- Independently prioritize competing needs across caseloads ranging from approximately 8–15 active patients to as many as 50 patients during weekend coverage.
Clinical Social Work Intern
Tenne Wordsworth
Warrenton, VA
05.2023 - 08.2023
- Provided individual and family counseling under LCSW supervision, applying clinical assessment and therapeutic intervention skills to address behavioral and psychosocial needs.
- Revised the internship onboarding program to support training and integration of future social work interns.
Social Worker Assistant
Michael Beattie
Vienna, VA
08.2022 - 03.2023
- Coordinated ongoing case follow-up and services for individuals with disabilities and mental health needs using telephone, Zoom, CRM, and project management systems.
- Advocated for clients navigating government benefits, community resources, safety planning, and other services while coordinating communication with outside organizations.
- Maintained case-related follow-up, documentation, and communication while independently managing administrative and client-service responsibilities.
Respite Care Provider
Maria McCampbell
Woodbridge, VA
11.2021 - 03.2023
- Provided home-based support to individuals with disabilities, implementing individualized care plans focused on adaptive skills, self-advocacy, and quality of life.
- Monitored client progress and documented the effectiveness of interventions to support ongoing care planning.
Internship Student
VITAS Healthcare
Fairfax, VA
08.2021 - 05.2022
- Supported hospice patients and families through grief, crisis intervention, psychosocial support, advocacy, and connection to community resources.
- Managed ongoing communication and follow-up within a high-volume bereavement program, supporting a diverse caseload of individuals and families.
Behavior Therapist
The Center for Autism and Related Disorders
Sterling, VA
09.2017 - 06.2020
- Provided individualized behavioral services to children and adolescents with autism, intellectual disabilities, and related developmental needs, supporting adaptive functioning and individualized treatment goals.
- Collaborated with clients, families, clinical supervisors, and interdisciplinary teams to implement treatment plans, monitor progress, address behavioral concerns, and strengthen caregiver support.
- Served in leadership roles supporting crisis intervention, staff training and competency evaluation across multiple offices, as well as recruitment and onboarding activities.
Education
Master of Social Work - Clinical Social Work
Virginia Commonwealth University
Richmond, VA05-2026
Bachelor of Social Work - Minor in Well-Being
George Mason University
Fairfax, VA05-2022
Skills
- Medicaid LTSS Assessments
- Long-Term Services & Supports
- Care Coordination
- Comprehensive Assessments
- Care Planning
- Discharge Planning
- Medicaid & Benefits Navigation
- Home & Community-Based Services
- SNF/LTC Placement
- Home Health
- Hospice
- DME Coordination
- Social Determinants of Health
- Complex Case Management
- Patient & Family Education
- Community Resource Coordination
- Interdisciplinary Care Teams
- Epic
- Meditech
- WellSky/Careport
- Telephonic/Virtual Case Management
- Multicultural Competence
Certification
- Medicaid Long-Term Services and Supports, 06/01/23
- Human Research - Group 1 Social and Behavioral Research Certification, 08/01/2025
- Certified Mental Health First Aider, 11/01/21
Timeline
Clinical Social Work Intern
Tenne Wordsworth
05.2023 - 08.2023
Case Management Social Worker
UVA Health Culpeper Medical Center
03.2023 - Current
Social Worker Assistant
Michael Beattie
08.2022 - 03.2023
Respite Care Provider
Maria McCampbell
11.2021 - 03.2023
Internship Student
VITAS Healthcare
08.2021 - 05.2022
Behavior Therapist
The Center for Autism and Related Disorders
09.2017 - 06.2020
Master of Social Work - Clinical Social Work
Virginia Commonwealth University
Bachelor of Social Work - Minor in Well-Being
George Mason University