Licensed Social Worker – Care Coordination

Aunt Martha’s Health & Wellness, Inc.

Park Forest (IL)

On-site

USD 45,000 - 55,000

Full time

14 days+

Get more replies from employers

Send a job-specific resume in minutes.

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Paid Vacation

Paid Sick Time

Paid Holidays

Retirement Plan

EAP

Employee Discounts

Career Growth Opportunities

Job summary

Aunt Martha's Health & Wellness in Park Forest, IL seeks a Licensed Social Worker – Care Coordination. This full-time role supports high- and medium-risk patients through psychosocial assessments, individualized care plans, and connections to community resources to improve access and outcomes.

The ideal candidate holds an Illinois LSW license, a social work degree, and experience with EHR systems and care transitions, collaborating with physicians, behavioral health staff, and community partners

Qualifications

Bachelor's or Master's degree in Social Work from an accredited program.
Current Illinois Licensed Social Worker (LSW) license in good standing.
Experience using Electronic Health Records and Microsoft Office.
Reliable transportation and ability to travel between sites.

Responsibilities

Coordinate medical, behavioral health, and social service needs for assigned patients.
Complete psychosocial and SDOH assessments.
Develop and monitor individualized care plans with SMART goals.
Coordinate referrals and monitor outcomes.

Skills

Communication

Organization

Documentation

Travel readiness

Education

Bachelor's or Master's in Social Work

Illinois LSW license

Tools

Electronic Health Records

Microsoft Office

Job description

Licensed Social Worker – Care Coordination

Regular Full-Time Park Forest, IL, US

Salary Range: $21.63 To $26.44 Annually

Location: Park Forest, IL (Ability to travel to other Aunt Martha's locations and community sites as needed.)
Department: Health Services - Care Coordination
Schedule: Full-Time
Compensation: $21.63-$26.44 per hour, based on experience and qualifications.

About Aunt Martha's Health & Wellness

At Aunt Martha's Health & Wellness, we are committed to improving the health and well-being of the communities we serve through compassionate, integrated care. Our Care Coordination team works collaboratively to address patients' medical, behavioral health, and social needs while helping individuals achieve healthier, more independent lives.

As a Licensed Social Worker – Care Coordination, you'll play a vital role in supporting high- and medium-risk patients through comprehensive care coordination, behavioral health support, and connections to community resources. This is an opportunity to join a mission-driven organization where you'll work alongside multidisciplinary healthcare professionals while making a meaningful impact on the lives of patients and families. If you're looking to grow your career in integrated healthcare and community-based care, we'd love to hear from you.

Position Overview

Under the supervision of the Care Coordination Nurse Supervisor, the Licensed Social Worker coordinates patients' medical, behavioral health, and social service needs to ensure timely access to appropriate care and community resources. This role performs psychosocial and Social Determinants of Health (SDOH) assessments, develops individualized care plans, supports transitions of care, and collaborates closely with providers, behavioral health staff, hospitals, and community partners.

The ideal candidate is compassionate, organized, and committed to improving patient outcomes through advocacy, care coordination, and evidence-based social work practice within the scope of an Illinois Licensed Social Worker (LSW) license.

Key Responsibilities

Care Coordination & Case Management

Coordinate medical, behavioral health, and social service needs for assigned patients.
Complete psychosocial and Social Determinants of Health (SDOH) assessments.
Develop, implement, and monitor individualized care management plans with SMART goals.
Prioritize patients based on risk level, urgency, and follow-up needs.
Promote patient self-management and support patients in achieving their care goals.
Provide ongoing case management, advocacy, referrals, and follow-up services.

Patient & Community Support

Connect patients with community resources, including behavioral health services, housing, food assistance, transportation, financial benefits, and other support programs.
Coordinate transitions of care following hospitalizations or skilled nursing facility stays.
Conduct follow-up calls for recently discharged patients and those at elevated risk for readmission.
Reinforce provider-approved health education and behavioral health education within the scope of practice.
Provide crisis intervention and de-escalation while following organizational protocols.
Collaborate with physicians, behavioral health providers, nurses, clinic staff, hospitals, and community partners.
Participate in interdisciplinary case reviews, supervision, and team meetings.
Assist with orientation of new staff and promote collaborative teamwork.
Coordinate referrals and monitor referral outcomes.

Documentation & Compliance

Document assessments, care plans, referrals, and patient encounters in Athena Electronic Health Record (EHR).
Maintain timely and accurate documentation in accordance with program requirements.
Complete reports and projects within established deadlines.
Maintain HIPAA compliance and uphold professional social work ethics.
Attend required meetings, trainings, and Core Curriculum sessions.

Qualifications

Required

Bachelor's or Master's Degree in Social Work from an accredited program.
Current Illinois Licensed Social Worker (LSW) license in good standing.
Reliable transportation and ability to travel between assigned sites and community locations.
Experience using Electronic Health Records and Microsoft Office applications.
Strong communication, organizational, and documentation skills.

Preferred

Experience working with behavioral health populations.
Experience addressing Social Determinants of Health (SDOH).
Experience coordinating transitions of care and connecting patients with community resources.
Experience in case management, crisis intervention, discharge planning, integrated care, or community health.
Bilingual English/Spanish proficiency strongly preferred.
Knowledge of trauma-informed care, behavioral health, and community resource navigation.

Benefits