Population Health Social Worker - Care Coordination

CommunityCare, Inc.; Tulsa (OK); On-site; USD 60,000 - 90,000; Full time

Job summary

CommunityCare, Inc. is seeking a Care Manager to lead care coordination and population health activities for our diverse member base in Oklahoma.

You will assess member needs, coordinate services, and facilitate referrals to behavioral health and substance use resources. In collaboration with physicians, nurses, and the interdisciplinary team, you will develop person-centered care plans, monitor outcomes, support transitions of care, and advance quality improvement while maintaining HIPAA

Qualifications

• Masters degree in a mental health field.
• Active, unrestricted Oklahoma social worker license.
• Active, unrestricted Oklahoma mental health professional license.
• Minimum of four years of related clinical experience.
• Managed behavioral health experience preferred.
• Health Care Sanctions background check required.

Responsibilities

• Conduct psychosocial assessments to identify member needs, barriers to care, health-related social needs, and social determinants of health.
• Evaluate member needs related to housing, food insecurity, transportation, financial strain, behavioral health, caregiver support, safety, health literacy, and access to community resources.
• Develop individualized, person-centered care plans in collaboration with members, caregivers, providers, and the interdisciplinary care team.
• Establish measurable goals and interventions that support improved health outcomes, member engagement, and appropriate utilization of services.
• Connect members to community-based organizations, public assistance programs, behavioral health services, long-term services and supports, and other appropriate resources.
• Collaborate with physicians, nurses, behavioral health specialists, pharmacists, case managers, utilization management staff, and community partners.
• Support transitions of care by assisting members after hospitalizations, emergency department visits, skilled nursing facility stays, or other care transitions.
• Assist members in navigating benefits, covered services, community support, and healthcare systems.
• Participate in population health initiatives designed to improve preventive care, chronic condition management, health equity, and quality outcomes.
• Utilize risk stratification tools, claims data, care gaps, utilization patterns, and referrals to prioritize outreach and interventions.
• Support programs targeting high-risk, high-cost, vulnerable, or underserved populations.
• Contribute to interventions focused on reducing avoidable emergency department visits, hospital readmissions, and gaps in care.
• Document assessments, interventions, care plans, member contacts, referrals, outcomes, and case closure activities accurately and timely in designated systems.
• Maintain compliance with CMS requirements, URAC accreditation standards, HIPAA, privacy and security regulations, and company policies.
• Monitor progress toward member goals and update care plans as needed.
• Participate in quality improvement activities, interdisciplinary case conferences, and performance improvement initiatives.
• Identify trends, barriers, and opportunities to improve population health outcomes and member experience.
• Support programs targeting high-risk, high-cost, vulnerable, or underserved populations.
• Contribute to interventions focused on reducing avoidable emergency department visits, hospital readmissions, and gaps in care.
• Document assessments, interventions, care plans, member contacts, referrals, outcomes, and case closure activities accurately and timely in designated systems.
• Maintain compliance with company policies, privacy and security regulations, HIPAA, CMS requirements, and URAC accreditation standards.
• Monitor progress toward member goals and update care plans as needed.
• Participate in quality improvement activities, interdisciplinary case conferences, and performance improvement initiatives.
• Identify trends, barriers, and opportunities to improve population health outcomes and member experience.
• Conduct provider clinical chart audits and provider trainings as needed.
• Serve as a resource for the team of alternative care options.
• Perform other job-related duties as required or assigned.

Skills

Mental health assessment

Problem solving

Critical thinking

Communication with providers

English fluency

Social determinants of health

Team collaboration

Office software

Education

Masters in mental health field

Oklahoma social worker license

Oklahoma mental health professional license

4+ years clinical experience

Managed behavioral health experience

Tools

Microsoft Office

Job description

CommunityCare, Inc. is seeking a Care Manager to lead care coordination and population health activities for our diverse member base in Oklahoma.

You will assess member needs, coordinate services, and facilitate referrals to behavioral health and substance use resources. In collaboration with physicians, nurses, and the interdisciplinary team, you will develop person-centered care plans, monitor outcomes, support transitions of care, and advance quality improvement while maintaining HIPAA