Care Coordination Social Worker for High-Risk Patients

Waco Family Medicine; Waco (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

Waco Family Medicine seeks a licensed social work professional to coordinate care for high-risk patients, integrating behavioral health and primary care services. The role emphasizes care planning, patient coaching on self-management, and collaboration with medical teams.

The ideal candidate holds an MSW (LMSW preferred) and brings experience in social services within healthcare settings, with strong communication and problem-solving skills to improve outcomes and reduce hospital utilization.

Qualifications

• MSW required with state licensure or in progress
• Experience in social services in healthcare settings preferred
• Strong communication and collaboration with medical teams

Responsibilities

• 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
• Provide appropriate supervised clinical care to meet Licensed Clinical Social Worker certification requirements

Skills

Case management

Disease management

Patient education

Interpersonal skills

Care coordination

Health assessments

Motivational interviewing

Written and oral communication

Education

Master of Social Work (MSW)

LMSW preferred

Job description

Waco Family Medicine seeks a licensed social work professional to coordinate care for high-risk patients, integrating behavioral health and primary care services. The role emphasizes care planning, patient coaching on self-management, and collaboration with medical teams.

The ideal candidate holds an MSW (LMSW preferred) and brings experience in social services within healthcare settings, with strong communication and problem-solving skills to improve outcomes and reduce hospital utilization.