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.

• Coordinate care to achieve desired health outcomes, enhance self-care capabilities, and reduce unnecessary healthcare costs.

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

• Conduct standardized comprehensive needs assessments.

• Recognize and address barriers to care while connecting patients with benefits and resources.

• Maintain a caseload of patients.

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

• Develop, execute, review, and update individualized patient care plans.

• Partner with ACMs, PCPs, specialists, and hospitalists to create patient-centered care plans.

• Evaluate social determinants of care and family circumstances.

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

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

• Manage resources to enhance care quality, improve patient experience, and minimize unnecessary costs and utilization.

• Support patients with advanced care planning and Advanced Directives.

• Document all communications with patients and care teams in the electronic medical record.

• 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 with community resources and services.

⛳️ Requirements

• A Bachelor's Degree is mandatory.

• A Master's Degree or licensure as required by the state of practice is necessary.

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

• Exceptional interpersonal communication and negotiation abilities are essential.

• Strong analytical, data management, and computer skills are needed.

• Basic understanding of healthcare and health education across the lifespan in a healthcare practice environment.

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

• Familiarity with community resources is advantageous.

• Flexibility to work non-traditional hours is required.

• Ability to thrive in a team-oriented environment.

• Proficiency in personal computer use is necessary.

• Experience with database entry and EMR documentation is essential.

• Basic skills in Excel are required.

• Highly organized and detail-oriented approach is essential.

• Willingness to accept responsibility and follow through on projects and activities is expected.

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

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

• Experience with PowerPoint is preferred.

• Proven success in improving the health of a distinct patient population in an ambulatory or community setting is preferred.

🏝️ Benefits

• Competitive salary.

• Incentives available.

• Referral bonuses offered.

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

• Comprehensive medical coverage.

• Dental coverage included.

• Vision coverage available.

• Prescription coverage provided.

• HSA/FSA options available.

• Life insurance offered.

• Access to mental health resources and discounts.

• Paid time off provided.

• Parental leave available.

• FMLA leave offered.

• Short-term disability coverage.

• Long-term disability coverage.

• Backup care for children and elderly family members.

• Tuition assistance provided.

• Opportunities for professional development.

• Support for continuing education available.