Social Work Care Manager (3402)

Waco Family Medicine; Waco (TX); On-site; USD 50,000 - 70,000; Full time

Job summary

Waco Family Medicine is seeking a Social Work Care Manager in Waco, Texas, to coordinate care for high-risk patients and enhance healthcare outcomes. Responsibilities include developing care plans and serving as a liaison among medical services.

This position requires a LMSW and offers opportunities to improve care coordination while utilizing community resources to enhance patients' quality of life. Join a dedicated team focused on improving patient health through comprehensive support and proactive management.

Qualifications

• Licensed Master of Social Work (LMSW) required.
• Experience in social services, counseling, or case management preferred.
• Knowledge of chronic physical and behavioral health conditions advantageous.

Responsibilities

• Coordinate and manage care for high-risk patients.
• Develop a tracking system for care coordination.
• Conduct comprehensive psychosocial needs assessments.
• Develop individualized care plans for disease prevention.

Skills

Case management skills

Interpersonal skills

Problem identification and care plan development

Professional interaction with healthcare professionals

Health assessment skills

Written and oral communication skills

Education

LMSW

4 Year Degree

Job description

Job Level: Experienced
Job Location: Central - Waco, TX 76707
Position Type: Full Time
Education Level: 4 Year Degree
Job Shift: Day
Job Category: Health Care

Primary Duties

• 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.

Other Duties

As assigned by supervisor.

Qualifications

Social Work Care Manager

Reports to: Director of Care Management and Social Work Care Management Team Lead

Education & Experience

• LMSW
• Preferred:
  • Experience in social services, counseling, case management, or vocational rehabilitation
  • Experience providing social services in healthcare settings

Skills

• Ability 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.

Physical and Mental Requirements

• Possess a valid Texas driver’s license and appropriate liability insurance.
• Access to personal transportation.
• Visual and auditory accuracy.
• Shift length varies.
• Indoor setting.
• Continuous use of computer.
• Long periods of sitting.
• Frequent use of telephone and/or smart devices.
• Continuous repetitive grasping and manipulation of both hands.
• Continuous conversational communication.
• Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing.
• Occasionally carrying, lifting, pushing and pulling up to 25 lbs.
• Occasionally working in confined, noisy, dusty areas.
• Understand/carry out simple/detailed, oral/written instructions.
• Memorize and retain instructions.
• Read and interpret detailed specifications.
• Mental competency.
• Tobacco non-user.
• Physical accommodations will be implemented where necessary and feasible.