Licensed Social Worker — Care Coordination & Community Support

Aunt Martha's Health & Wellness; Park Forest (IL); On-site; USD 45,000 - 55,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

Paid Vacation

Paid Sick Time

Paid Holidays

Retirement Plan

EAP

Employee Discounts

Career Growth

Job summary

Aunt Martha's Health & Wellness in Park Forest, IL is seeking a Licensed Social Worker – Care Coordination to join our Health Services team. You will coordinate medical, behavioral health, and social services for high- and medium-risk patients, perform psychosocial assessments, and develop individualized care plans under supervision.

The ideal candidate holds an Illinois LSW license, has strong communication and documentation skills, and is prepared to travel between sites to connect patients

Qualifications

• 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.

Responsibilities

• 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.
• 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.
• Document assessments, care plans, referrals, and patient encounters in Athena 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.

Skills

Communication skills

Organizational skills

Documentation skills

Education

Bachelor's or Master's Degree in Social Work

Tools

Athena EHR

Microsoft Office

Job description

Aunt Martha's Health & Wellness in Park Forest, IL is seeking a Licensed Social Worker – Care Coordination to join our Health Services team. You will coordinate medical, behavioral health, and social services for high- and medium-risk patients, perform psychosocial assessments, and develop individualized care plans under supervision.

The ideal candidate holds an Illinois LSW license, has strong communication and documentation skills, and is prepared to travel between sites to connect patients