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