Care Manager Social Worker

Requirements

• Perform in-home and telehealth care management visits to assess and determine social and behavioral status
• Work closely with Care Team to ensure collaboration and optimal patient outcomes
• Assess social determinants of health needs and develop a plan for addressing them
• Identify, vet, and build relationships with local Community-Based Organizations
• Educate patients on appropriate resources, assist with referral completion, and follow up for closure outcomes
• Serve as subject matter expert on social determinants for other members of the Care Team
• Complete behavioral, environmental, and social support assessments
• Deliver individual, family and group education on living with chronic illness
• Engage family and social support groups in the education and care of patients
• Assess patients and refer to behavioral health specialists if diagnosis and treatment needed
• Help patients to understand, accept and follow medical and lifestyle recommendations
• Review and document patient updates and progress in care management platform

Benefits

• Comprehensive Benefits
• Financial & Retirement Support
• Time Off & Leave
• Wellness & Growth