Social Work Care Manager -CPW (4426)

WACO FAMILY MEDICINETemple, TX
Onsite

About The Position

The Social Work Care Manager - CPW (Children & Pregnant Women) role focuses on coordinating and managing care for high-risk children and pregnant women to improve health outcomes. This position involves assessing and responding to a wide range of patient needs, including psychosocial, financial, functional, cognitive, and medical aspects. The Care Manager will identify and address gaps in patient care through proactive outreach and follow-up services, and will utilize the patient's support systems to facilitate reaching health goals. Monitoring and responding to changes in patient condition, resources, or services is crucial. This role also serves as a liaison between primary care, specialty, and behavioral health services to ensure coordinated patient treatment plans. The position requires developing individualized care plans with short and long-term medical and behavioral health treatment goals, assisting patients in navigating the healthcare system, and applying knowledge of community resources to address care gaps or improve quality of life.

Requirements

  • Knowledge of health care conditions and needs of children and pregnant women.
  • Ability to learn and apply case management and patient education skills.
  • Strong interpersonal skills with the ability to build effective relationships across medical teams and with patients.
  • Proficiency in problem identification and care plan development.
  • Professional interaction skills with medical providers and other healthcare professionals.
  • Skillfully conduct health assessments and screenings.
  • Ability to learn and apply evidence-based behavioral strategies.
  • Strong written and oral communication skills.
  • Possess a valid Texas driver’s license and appropriate liability insurance.
  • Access to personal transportation.
  • Visual and auditory accuracy.
  • Continuous use of computer.
  • Frequent use of telephone and/or smart devices.
  • Continuous repetitive grasping and manipulation of both hands.
  • Continuous conversational communication.
  • Understand/carry out simple/detailed, oral/written instructions.
  • Memorize and retain instructions.
  • Read and interpret detailed specifications.
  • Mental competency.
  • Tobacco non-user.

Nice To Haves

  • LMSW Preferred
  • Experience in social services, counseling, or case management
  • Experience providing social services in healthcare settings
  • Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing
  • Occasionally carrying, lifting, pushing and pulling of up to 25 lbs.
  • Occasionally working in confined, noisy, dusty areas

Responsibilities

  • Coordinate and manage care for high-risk children and/or pregnant women to improve outcomes.
  • Assess and respond to psychosocial, financial, functional, cognitive and medical needs.
  • Identify and address gaps in patient care through proactive outreach and follow-up services.
  • Identify and utilize patient’s systems of support and facilitators for reaching health goals.
  • Monitor and respond appropriately to changes in patients’ condition, resources, or services.
  • Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans.
  • Conduct comprehensive psychosocial needs assessments.
  • Develop individualized care plans focusing on short and long-term medical and behavioral health treatment goals.
  • Assist patients in navigating the healthcare system.
  • Apply knowledge of community resources to address care gaps or improve quality of life conditions.
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