Social Work Care Manager

WACO FAMILY MEDICINE • Waco, TX

2d • Onsite

About The Position

The Social Work Care Manager coordinates care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization. The role supports coordinated treatment across primary care, specialty care, and behavioral health services; identifies gaps in care; and helps patients manage chronic conditions and navigate the healthcare system. The position also provides supervised clinical care toward Licensed Clinical Social Worker certification requirements.

This is a full-time, day-shift position located at Madison Cooper Clinic in Waco, Texas. It reports to the Director of Care Management and the Director of Integrated Behavioral Health. A four-year degree is listed as the education level, and an LMSW is preferred.

Requirements

• Four-year degree.
• Valid Texas driver’s license and appropriate liability insurance.
• Access to personal transportation.
• Ability to learn and apply case management, disease management, and patient education skills.
• Strong interpersonal skills and 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.
• Ability to learn and apply knowledge of chronic physical and behavioral health conditions.
• Ability to conduct health assessments and screenings skillfully.
• Ability to learn and apply evidence-based behavioral strategies, including motivational interviewing.
• Strong written and oral communication skills.
• Meet the listed physical and mental requirements, including continuous computer use and communication, prolonged sitting, and occasional physical activities and lifting up to 25 pounds.
• Tobacco non-user.

Nice To Haves

• LMSW preferred.
• Experience in social services, counseling, case management, or vocational rehabilitation.
• Experience providing social services in healthcare settings.

Responsibilities

• Coordinate and manage care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization.
• Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals.
• Identify and address gaps in patient care through proactive outreach and follow-up services.
• Implement standing delegated orders and management protocols.
• Participate in or lead regular Care Team meetings.
• Serve as a liaison between primary care, specialty, and behavioral health services to support coordinated patient treatment plans.
• Coach patients on self-management for chronic conditions.
• Conduct comprehensive psychosocial needs assessments.
• Develop individualized care plans focused on disease prevention and improved self-care.
• 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.

What This Job Offers

• Job Type: Full-time