Social Work Care Manager

PRIMARY DUTIES

• 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 for coordinated patient treatment plans.
• Offer coaching to patients on self-management for chronic conditions.
• Conduct comprehensive psychosocial needs assessments.
• Develop individualized care plans focusing on disease prevention and self-care improvement.
• Assist patients in navigating the healthcare system by coordinating with specialty care
• Apply knowledge of community resources to address care gaps or improve quality of life conditions.

OTHER DUTIES

• As assigned by supervisor.

Social Work Care Manager

REPORTS TO: Director of Care Management and Social Work Care Management Team Lead

EDUCATION & EXPERIENCE

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

SKILLS

• Ability to learn and apply case management, disease 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.
• Ability to learn and apply knowledge of chronic physical and behavioral health conditions.
• Skillfully conduct health assessments and screenings.
• Ability to learn and apply evidence-based behavioral strategies, including motivational interviewing.
• Strong written and oral communication skills.

PHYSICAL AND MENTAL REQUIREMENTS

• Possess a valid Texas driver’s license and appropriate liability insurance
• Access to personal transportation
• Visual and auditory accuracy
• Shift length varies
• Indoor setting
• 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
• 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
• Understand/carry out simple/detailed, oral/written instructions
• Memorize and retain instructions
• Read and interpret detailed specifications
• Mental competency
• Tobacco non-user
• Physical accommodations will be implemented where necessary and feasible