Chronic Care Social Worker & Care Coordinator

All Aviation Jobs; Brookfield (CT); On-site; USD 52,000 - 72,000; Full time

Job summary

ROMTech is seeking a Contract Social Worker to support the Chronic Care Management program by performing psychosocial assessments, care coordination, and resource navigation for patients with chronic conditions. This role enhances outcomes by reducing barriers to care and aligning with CMS guidelines.

You will collaborate with interdisciplinary teams, document in EHR/CCM platforms, and guide patients to housing, transportation, and services while maintaining HIPAA compliance.

Qualifications

• Understanding of social determinants of health and care coordination requirements.
• Experience in care management or population health is advantageous.
• LCSW or Florida license is preferred (externally required for practice).

Responsibilities

• Conduct psychosocial assessments to identify patient needs and barriers to care.
• Collaborate with care teams to develop and execute individualized care plans.
• Provide short-term counseling and emotional support for patients with chronic conditions.
• Identify and connect patients to housing, transportation, food, and financial resources.
• Assist with care transitions and post-discharge support.
• Maintain HIPAA-compliant documentation in EHR/CCM systems.

Skills

Care coordination

Strong communication

Independent work

Documentation

Organizational skills

Bilingual (English/Spanish)

Education

Bachelor’s or MSW in Social Work

Tools

EHR systems

Telehealth platforms

Job description

ROMTech is seeking a Contract Social Worker to support the Chronic Care Management program by performing psychosocial assessments, care coordination, and resource navigation for patients with chronic conditions. This role enhances outcomes by reducing barriers to care and aligning with CMS guidelines.

You will collaborate with interdisciplinary teams, document in EHR/CCM platforms, and guide patients to housing, transportation, and services while maintaining HIPAA compliance.