Care Coordination Specialist – Social Work & Behavioral Health

Waco Family Medicine; Waco (TX); Sur place; USD 52 000 - 75 000; Plein temps

Résumé du poste

Waco Family Medicine in Waco, TX is seeking an LMSW social worker to coordinate care for high-risk patients within a healthcare setting. You will develop care plans, lead care team activities, and liaise across primary care, specialty, and behavioral health services to optimize patient outcomes.

Responsibilities include psychosocial assessments, patient coaching for self-management, and applying community resources to close care gaps.

Qualifications

• LMSW licensure required.
• Experience in social services, counseling, case management, or vocational rehabilitation.
• Experience providing social services in healthcare settings.

Responsabilités

• Coordinate and manage care for high-risk patients to improve outcomes and minimize hospital utilization.
• Develop and maintain a tracking system for seamless care coordination across medical services.
• 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.
• Provide appropriate supervised clinical care to meet Licensed Clinical Social Worker certification requirements.

Connaissances

Case management

Disease management

Patient education

Interpersonal skills

Care planning

Communication

Chronic care knowledge

Health assessments

Motivational interviewing

Formation

LMSW

Description du poste

Waco Family Medicine in Waco, TX is seeking an LMSW social worker to coordinate care for high-risk patients within a healthcare setting. You will develop care plans, lead care team activities, and liaise across primary care, specialty, and behavioral health services to optimize patient outcomes.

Responsibilities include psychosocial assessments, patient coaching for self-management, and applying community resources to close care gaps.