Social Work Care Manager

Waco Family Medicine; Waco (TX); Vor Ort; USD 55.000 - 75.000; Vollzeit

Zusammenfassung

Waco Family Medicine seeks a licensed social work professional to coordinate care for high-risk patients, integrating behavioral health and primary care services. The role emphasizes care planning, patient coaching on self-management, and collaboration with medical teams.

The ideal candidate holds an MSW (LMSW preferred) and brings experience in social services within healthcare settings, with strong communication and problem-solving skills to improve outcomes and reduce hospital utilization.

Qualifikationen

• MSW required with state licensure or in progress
• Experience in social services in healthcare settings preferred
• Strong communication and collaboration with medical teams

Aufgaben

• Coordinate and manage care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization
• Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals
• Identify and address gaps in patient care through proactive outreach and follow-up services
• Implement standing delegated orders and management protocols
• Participate in or lead regular Care Team meetings
• Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans
• Offer coaching to patients on self-management for chronic conditions
• Conduct comprehensive psychosocial needs assessments
• Develop individualized care plans focusing on disease prevention and self-care improvement
• Assist patients in navigating the healthcare system by coordinating with specialty care
• Apply knowledge of community resources to address care gaps or improve quality of life conditions
• Provide appropriate supervised clinical care to meet Licensed Clinical Social Worker certification requirements

Kenntnisse

Case management

Disease management

Patient education

Interpersonal skills

Care coordination

Health assessments

Motivational interviewing

Written and oral communication

Ausbildung

Master of Social Work (MSW)

LMSW preferred

Jobbeschreibung

REPORTS TO: Director of Care Management and Director of Integrated Behavioral HealthEDUCATION & EXPERIENCELMSWPreferred:Experience in social services, counseling, case management, or vocational rehabilitationExperience providing social services in healthcare settingsSKILLSAbility to learn and apply case management, disease management, and patient education skills.Strong interpersonal skills with the ability to build effective relationships across medical teams and with patients.Proficiency in problem identification and care plan development.Professional interaction skills with medical providers and other healthcare professionals.Ability to learn and apply knowledge of chronic physical and behavioral health conditions.Skillfully conduct health assessments and screenings.Ability to learn and apply evidence-based behavioral strategies, including motivational interviewing.Strong written and oral communication skills.PRIMARY DUTIESCoordinate and manage care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization.Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals.Identify and address gaps in patient care through proactive outreach and follow-up services.Implement standing delegated orders and management protocols.Participate in or lead regular Care Team meetings.Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans.Offer coaching to patients on self-management for chronic conditions.Conduct comprehensive psychosocial needs assessments.Develop individualized care plans focusing on disease prevention and self-care improvement.Assist patients in navigating the healthcare system by coordinating with specialty careApply knowledge of community resources to address care gaps or improve quality of life conditions.Provide appropriate supervised clinical care to meet Licensed Clinical Social Worker certification requirements.OTHER DUTIESAs assigned by supervisor.PHYSICAL AND MENTAL REQUIREMENTSPossess a valid Texas driver’s license and appropriate liability insuranceAccess to personal transportationVisual and auditory accuracyShift length variesIndoor settingContinuous use of computerLong periods of sittingFrequent use of telephone and/or smart devicesContinuous repetitive grasping and manipulation of both handsContinuous conversational communicationOccasional reaching, walking, squatting, bending, kneeling, twisting and climbingOccasionally carrying, lifting, pushing and pulling of up to 25 lbs.Occasionally working in confined, noisy, dusty areasUnderstand/carry out simple/detailed, oral/written instructionsMemorize and retain instructionsRead and interpret detailed specificationsMental competencyTobacco non-userPhysical accommodations will be implemented where necessary and feasible