Care Manager - Social Worker

Monogram Health; Savannah (GA); On-site; USD 70,000 - 86,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

401k with employer match

Paid time off and holidays

Job summary

Monogram Health seeks a licensed Social Worker to join our in-home care teams, delivering autonomous clinical care alongside nurses and APPs. You will assess behavioral and environmental needs, address social determinants, and guide clinically informed interventions in collaboration with multidisciplinary teams.

The role emphasizes independent judgment, with LCSW licensure required in the deployment state and preferred 2+ years in care management for complex chronic patients.

Qualifications

• Master’s degree in social work and licensure in the posting state.
• Active LCSW license in the state of employment.
• BLS certification required; certification support provided by the company.
• 2+ years of experience in care management preferred.

Responsibilities

• Conduct in-home and telehealth care management visits to assess social and behavioral status.
• Collaborate with Care Team to optimize patient outcomes.
• Assess social determinants and develop intervention plans.
• Engage local Community-Based Organizations for referrals.
• Educate patients and ensure referral completion; follow up.
• Document updates in care management platform.

Education

Master's degree in social work

ASWB masters or clinical exam

Tools

Microsoft Office

Job description

Job Description: Care Manager, Social Worker

Monogram Health is seeking a Social Worker to join our integrated in-home care teams, working alongside Nurse Care Managers and Advanced Practice Providers. Our patients often face complex chronic medical conditions coupled with behavioral health challenges, making the social worker a critical clinical expert within the care team.

In this role, social workers practice with a high degree of autonomy. Responsibilities include assessing patients' behavioral, social, and environmental needs; utilizing validated screening tools; identifying behavioral health concerns; determining when clinical intervention is warranted; and serving as a trusted behavioral health resource for fellow clinicians. Because this position requires independent clinical judgment and practice, the successful candidate will hold an active, unrestricted LCSW license in the state of employment.

Social workers who require ongoing clinical supervision to practice independently, including those at the master's or associate level pursuing full licensure, are not eligible for this role.

This is a unique opportunity to apply advanced clinical social work skills within a multidisciplinary, home-based care model focused on improving outcomes for some of the highest-need patients in healthcare.

Your Impact

The care team works with patients face-to-face, over the phone, and through telehealth to identify and address social determinants of health. The goal is to build a patient’s social support network, navigate behavioral challenges, and generally help patients through a traumatic diagnosis and life-changing disease. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do.â¯

Compensation

The base salary range for this role is $69,628 to $85,696 and reflects the range of experience and qualifications we may consider. Final compensation will be determined based on geographic location and job-related factors such as experience, skills, education, certifications, and internal compensation considerations. While a larger range is posted, most offers will typically fall within a narrower band based on these factors.

In addition to base salary, this role is eligible for additional compensation, including bonus opportunities and a comprehensive benefits package.

Roles And Responsibilities

• Perform in-home and telehealthâ¯care management visits to assess and determine social and behavioral statusâ¯
• Work closely with Care Team to ensure collaboration and optimal patient outcomes
• Assess social determinants of health needs and develop a plan for addressing them
• Identify, vet, and build relationships with local Community-Based Organizationsâ¯
• Educate patients on appropriate resources, assist with referral completion, and follow up for closure outcomes
• Serve as subject matter expert on social determinants for other members of the Care Teamâ¯
• Complete behavioral, environmental, and social support assessments
• Deliver individual, family and group education on living with chronic illnessâ¯
• Engage family and social support groups in the education and care of patientsâ¯
• Assess patients and refer to behavioral health specialists if diagnosis and treatment neededâ¯
• Help patients to understand, accept and follow medical and lifestyle recommendationsâ¯
• Review and document patient updates and progress in care management platform

Position Requirements

• This position involves telephonic visits with some car travel to patients’ homes
• Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding.
• Currently licensed as a LCSW in the posted state
• Master’s degree in social work and passed ASWB masters or clinical exam
• Rare domestic travel may be required to Brentwood, TN
• Self-starter with the ability to work independently with minimal supervision
• Ability to show empathy and quickly build relationships with patients and local CBOs
• Preferred: 2+ years previous experience working in care management and/or with chronic illness
• Excellent verbal communication skills both in person and on the phone
• Familiarity with Microsoft Office and mobile phone and web-based applications

Benefits

• Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts
• Financial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resources
• Time Off & Leave – 20 PTO days, 7 paid holidays, and 1 floating day to make your own, and paid parental leave
• Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts

About Monogram Health

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.

Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.

Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.â¯