Licensed Social Worker – Care Coordination

AUNT MARTHAS HEALTH AND WELLNESS•Park Forest, IL

1d•Hybrid

About The Position

At Aunt Martha's Health & Wellness, we are committed to improving the health and well-being of the communities we serve through compassionate, integrated care. Our Care Coordination team works collaboratively to address patients' medical, behavioral health, and social needs while helping individuals achieve healthier, more independent lives. As a Licensed Social Worker – Care Coordination, you'll play a vital role in supporting high- and medium-risk patients through comprehensive care coordination, behavioral health support, and connections to community resources. This is an opportunity to join a mission-driven organization where you'll work alongside multidisciplinary healthcare professionals while making a meaningful impact on the lives of patients and families. If you're looking to grow your career in integrated healthcare and community-based care, we'd love to hear from you.

Requirements

Bachelor's or Master's Degree in Social Work from an accredited program.
Current Illinois Licensed Social Worker (LSW) license in good standing.
Valid Illinois driver's license.
Current automobile insurance.
Reliable transportation and ability to travel between assigned sites and community locations.
Experience using Electronic Health Records and Microsoft Office applications.
Strong communication, organizational, and documentation skills.

Nice To Haves

Experience working with behavioral health populations.
Experience addressing Social Determinants of Health (SDOH).
Experience coordinating transitions of care and connecting patients with community resources.
Experience in case management, crisis intervention, discharge planning, integrated care, or community health.
Bilingual English/Spanish proficiency strongly preferred.
Knowledge of trauma-informed care, behavioral health, and community resource navigation.

Responsibilities

Coordinate medical, behavioral health, and social service needs for assigned patients.
Complete psychosocial and Social Determinants of Health (SDOH) assessments.
Develop, implement, and monitor individualized care management plans with SMART goals.
Prioritize patients based on risk level, urgency, and follow-up needs.
Promote patient self-management and support patients in achieving their care goals.
Provide ongoing case management, advocacy, referrals, and follow-up services.
Connect patients with community resources, including behavioral health services, housing, food assistance, transportation, financial benefits, and other support programs.
Coordinate transitions of care following hospitalizations or skilled nursing facility stays.
Conduct follow-up calls for recently discharged patients and those at elevated risk for readmission.
Reinforce provider-approved health education and behavioral health education within the scope of practice.
Provide crisis intervention and de-escalation while following organizational protocols.
Collaborate with physicians, behavioral health providers, nurses, clinic staff, hospitals, and community partners.
Participate in interdisciplinary case reviews, supervision, and team meetings.
Assist with orientation of new staff and promote collaborative teamwork.
Coordinate referrals and monitor referral outcomes.
Document assessments, care plans, referrals, and patient encounters in Athena Electronic Health Record (EHR).
Maintain timely and accurate documentation in accordance with program requirements.
Complete reports and projects within established deadlines.
Maintain HIPAA compliance and uphold professional social work ethics.
Attend required meetings, trainings, and Core Curriculum sessions.