Social Worker Care Coordinator – Population Health

This is a fully remote position, open to applicants in Illinois, +2 more states.

📋 Description

• Deliver clinical care management services to eligible patients to facilitate desired health outcomes, enhance self-care, and minimize unnecessary care expenses.

• Collaborate with the Interdisciplinary Team, Ambulatory Care Manager, and Care Coordinator to recognize and address patient needs.

• Conduct thorough needs assessments and tackle barriers to care.

• Maintain a patient caseload in accordance with department policies.

• Identify, enroll, and oversee patients within Complex Case Management.

• Create, implement, evaluate, and revise patient-centered care plans.

• Work in partnership with ACMs, PCPs, Specialists, and Hospitalists.

• Evaluate social determinants of care and family circumstances, and establish care objectives.

• Perform patient outreach and document interactions in the electronic medical record.

• Identify, execute, and monitor referrals to healthcare and community resources.

• Manage resources to enhance care, patient experience, and utilization.

• Assist patients with advance care planning and Advanced Directives.

• Coordinate services for disabled-status and facilitate post-acute rehabilitation or long-term care placements.

• Advocate for patients and connect them with suitable community resources and services.

⛳️ Requirements

• Bachelor’s Degree is required.

• Master’s Degree or licensure as mandated by the state of practice is required.

• Bachelor’s or Master’s Degree in Social Work is preferred.

• Case Management certification, LSW, or LCSW is preferred.

• 2–3 years of experience in acute care, home health, or case management is required.

• Outstanding interpersonal communication and negotiation skills.

• Strong analytical, data management, and computer skills.

• Basic understanding of healthcare and health education across the lifespan.

• Ability to engage with individuals, groups, and families.

• Familiarity with community resources.

• Willingness to work non-traditional hours.

• Ability to collaborate effectively in a team environment.

• Proficient personal computer skills.

• Experience with database entry and EMR documentation.

• PowerPoint experience is preferred.

• Basic skills in Excel.

• Highly organized and detail-oriented.

• Takes responsibility and follows through on projects and activities.

• Proven success in improving the health of a specific patient population is preferred.

🏝️ Benefits

• Competitive pay.

• Incentives.

• Referral bonuses.

• 403(b) plan with employer contributions (when eligible).

• Medical, dental, vision, and prescription coverage.

• HSA/FSA options.

• Life insurance.

• Mental health resources and discounts.

• Paid time off.

• Parental and FMLA leave.

• Short- and long-term disability.

• Backup care for children and elders.

• Tuition assistance.

• Opportunities for professional development.

• Support for continuing education.