Social Work Care Manager
About The Position
The Social Work Care Manager coordinates care for high-risk patients to improve outcomes and reduce unnecessary hospital utilization. The role supports seamless coordination across medical services, including transitions and referrals, and works with primary care, specialty care, and behavioral health services to support coordinated treatment plans. The position also involves patient outreach, psychosocial assessment, individualized care planning, coaching on chronic-condition self-management, and helping patients navigate healthcare and community resources. The role may provide supervised clinical care toward Licensed Clinical Social Worker certification requirements.
Requirements
- Experience in social services, counseling, case management, or vocational rehabilitation.
- Experience providing social services in healthcare settings.
- Ability to learn and apply case management, disease management, and patient education skills.
- Strong interpersonal skills and ability to build effective relationships with medical teams and patients.
- Ability to identify problems and develop care plans.
- Professional interaction skills with medical providers and other healthcare professionals.
- Ability to learn and apply knowledge of chronic physical and behavioral health conditions.
- Ability to conduct health assessments and screenings.
- Ability to learn and apply evidence-based behavioral strategies, including motivational interviewing.
- Strong written and oral communication skills.
- Valid Texas driver’s license and appropriate liability insurance.
- Access to personal transportation.
- Tobacco non-user.
Nice To Haves
- LMSW preferred.
Responsibilities
- Coordinate and manage care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization.
- Develop and maintain a tracking system for care coordination across medical services, including transitions and referrals.
- Identify and address gaps in patient care through proactive outreach and follow-up.
- Implement standing delegated orders and management protocols.
- Participate in or lead regular Care Team meetings.
- Serve as a liaison among primary care, specialty care, and behavioral health services to support coordinated treatment plans.
- Coach patients on self-management of chronic conditions.
- Conduct comprehensive psychosocial needs assessments.
- Develop individualized care plans focused on disease prevention and self-care improvement.
- Help patients navigate the healthcare system by coordinating with specialty care.
- Apply knowledge of community resources to address care gaps or improve quality of life.
- Provide appropriate supervised clinical care to meet Licensed Clinical Social Worker certification requirements.
- Perform other duties as assigned by the supervisor.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
