Chronic Care Social Worker — Telehealth & Care Coordination

ROMTech; Brookfield (CT); On-site; USD 55,000 - 75,000; Full time

Job summary

ROMTech, a medical technology company, seeks a Contract Social Worker to support the Chronic Care Management program. You will perform psychosocial assessments, coordinate care, and connect patients with housing, transportation, and financial resources, ensuring CMS CCM guidelines are followed.

Based in Florida, you will collaborate with interdisciplinary teams, document in EHR/ CCM platforms, and provide education to improve adherence and outcomes for patients with chronic conditions.

Qualifications

• Requires Florida Social Work license (active).
• MSW strongly preferred; BSW/ MSW acceptable with experience.
• Experience in care management, population health, or chronic disease management helpful.

Responsibilities

• Conduct psychosocial assessments to identify patient needs, barriers to care, and social determinants of health.
• Coordinate with interdisciplinary teams to develop and execute individualized care plans.
• Provide short-term supportive counseling and education to patients managing chronic conditions.
• Identify and connect patients with community resources (housing, transportation, food assistance, behavioral health, financial services).
• Support adherence to care plans and medications through structured follow-up and coaching.
• Assist with care transitions, including post-discharge coordination and patient support.
• Maintain compliant documentation in EHR/ CCM platforms and participate in care consultations.

Skills

Care coordination

Psychosocial assessments

Interdisciplinary collaboration

Documentation

Verbal communication

Education

MSW preferred

Bachelor’s or Master’s in Social Work

Tools

EHR systems

Telehealth platforms

Job description

ROMTech, a medical technology company, seeks a Contract Social Worker to support the Chronic Care Management program. You will perform psychosocial assessments, coordinate care, and connect patients with housing, transportation, and financial resources, ensuring CMS CCM guidelines are followed.

Based in Florida, you will collaborate with interdisciplinary teams, document in EHR/ CCM platforms, and provide education to improve adherence and outcomes for patients with chronic conditions.