Chronic Care Social Worker - CCM (Florida)

ROM Technologies, Inc.; Brookfield (CT); On-site; USD 51,000 - 73,000; Full time

Job summary

ROMTech in Brookfield, CT seeks a Contract Social Worker to support the Chronic Care Management program, providing psychosocial assessments, care coordination, and resource navigation for patients with chronic and complex conditions. This role requires a Florida Social Work License and focuses on improving outcomes, adherence, and reducing barriers to care.

The position involves interdisciplinary collaboration, HIPAA compliance, and CMS CCM guideline alignment, with day shifts and a strong

Qualifications

• Bachelor’s or Master’s degree in Social Work (MSW strongly preferred).
• Active Florida Social Work License required for practice.
• 2–3 years of care management, medical social work, or chronic disease management experience.
• Experience with Medicare and high-risk populations is a plus.

Responsibilities

• Conduct psychosocial assessments to identify patient needs and barriers.
• Coordinate care plans with interdisciplinary teams to support CCM goals.
• Provide short-term counseling and emotional support for chronic conditions.
• Facilitate access to community resources (housing, transportation, food, behavioral health, financial services).
• Educate and follow up to support adherence to care plans and medications.
• Assist with care transitions and post-discharge coordination.
• Maintain compliant documentation in EHR/ CCM platforms.
• Participate in case discussions to optimize patient outcomes.
• Ensure activities align with HIPAA and CMS CCM guidelines.

Skills

social determinants of health

care coordination

communication skills

interpersonal skills

independent work

caseload management

documentation skills

navigate resources

telehealth familiarity

EHR proficiency

bilingual (English/Spanish)

Education

MSW strongly preferred

Bachelor's or Master’s in Social Work

Tools

EHR systems

Telehealth platforms

Job description

ROMTech in Brookfield, CT seeks a Contract Social Worker to support the Chronic Care Management program, providing psychosocial assessments, care coordination, and resource navigation for patients with chronic and complex conditions. This role requires a Florida Social Work License and focuses on improving outcomes, adherence, and reducing barriers to care.

The position involves interdisciplinary collaboration, HIPAA compliance, and CMS CCM guideline alignment, with day shifts and a strong