About The Position

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.

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.
  • LMSW
  • Possess a valid Texas driver’s license and appropriate liability insurance
  • Access to personal transportation
  • Visual and auditory accuracy
  • Continuous use of computer
  • Long periods of sitting
  • 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

  • Experience in social services, counseling, or case management
  • Experience providing social services in healthcare settings

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.
  • As assigned by supervisor.
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