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 designated eligible patients.

• Facilitate care to achieve optimal health outcomes, enhance self-care capabilities, and minimize unnecessary healthcare costs.

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

• Conduct standardized comprehensive needs assessments.

• Recognize and address barriers to care, aligning patients with available benefits and resources.

• Maintain a patient caseload in accordance with department policies.

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

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

• Partner with ACMs, primary care providers, specialists, and hospitalists.

• Perform assessments of social determinants of care for patients and their families.

• Engage in 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 quality and patient experience while reducing unnecessary costs and usage.

• Support patients with advanced care planning and the completion of Advanced Directives.

• Coordinate services for individuals with disabilities and facilitate their placement in post-acute rehabilitation or long-term care facilities.

• Advocate for patients' physical and socioeconomic needs, connecting them to community resources.

⛳️ Requirements

• Bachelor’s Degree is required.

• Master’s Degree or state-required licensure is preferred.

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

• Preference for a Bachelor’s or Master’s Degree in Social Work.

• Certification in Case Management, LSW, or LCSW is preferred.

• Outstanding interpersonal communication and negotiation skills.

• Strong skills in analysis, data management, and computer usage.

• Basic understanding of healthcare and health education throughout the lifespan in a clinical health environment.

• Capability to work with individuals, groups, and families.

• Familiarity with community resources is essential.

• Flexibility to work non-traditional hours is required.

• Ability to collaborate effectively in a team environment.

• Proficient personal computer skills.

• Experience with database entry and electronic medical record documentation.

• Preference for experience with PowerPoint.

• Basic proficiency in Excel is needed.

• Highly organized and detail-oriented.

• Takes responsibility and follows through on projects and activities.

🏝️ Benefits

• Competitive salary.

• Performance incentives.

• Referral bonuses.

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

• Comprehensive medical, dental, vision, and prescription coverage.

• Options for Health Savings Account (HSA) or Flexible Spending Account (FSA).

• Life insurance coverage.

• Access to mental health resources and discounts.

• Paid time off.

• Parental leave and Family Medical Leave Act (FMLA) leave.

• Short- and long-term disability benefits.

• Backup care services for children and elderly family members.

• Tuition assistance programs.

• Opportunities for professional development.

• Support for continuing education.