Social Work Care Manager -CPW

Waco Family Medicine; Temple (TX); On-site; USD 52,000 - 70,000; Full time

Job summary

Waco Family Medicine in Temple, TX is seeking a Social Work Care Manager (LMSW) to coordinate and manage care for high-risk children and pregnant women. You will assess psychosocial, financial, functional and medical needs and develop individualized care plans while collaborating with medical teams.

The role requires strong communication, patient advocacy and effective navigation of community resources; funded through October 31, 2027, with potential extension.

Qualifications

• LMSW preferred; healthcare social work experience is desirable.
• Ability to assess psychosocial, financial, functional and medical needs.
• Strong communication and collaboration with medical teams.

Responsibilities

• Coordinate and manage care for high-risk children and/or pregnant women.
• Assess psychosocial, financial, functional and medical needs; follow-up on gaps.
• Develop individualized care plans focusing on medical and behavioral goals.
• Liaise between primary care, specialty and behavioral health services.
• Assist patients in navigating the healthcare system and accessing resources.
• Conduct comprehensive psychosocial needs assessments and outreach.

Skills

Health knowledge

Case management

Patient education

Interpersonal skills

Care plan development

Written and oral communication

Education

LMSW

Job description

SKILLSKnowledge of health care conditions and needs of children and pregnant women.Ability to learn and apply case 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.Skillfully conduct health assessments and screenings.Ability to learn and apply evidence-based behavioral strategies.Strong written and oral communication skills.PRIMARY DUTIESCoordinate and manage care for high-risk children and/or pregnant women to improve outcomes.Assess and respond to psychosocial, financial, functional, cognitive and medical needs.Identify and address gaps in patient care through proactive outreach and follow-up services.Identify and utilize patient’s systems of support and facilitators for reaching health goals.Monitor and respond appropriately to changes in patients’ condition, resources, or services.Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans.Conduct comprehensive psychosocial needs assessments.Develop individualized care plans focusing on short and long-term medical and behavioral health treatment goals.Assist patients in navigating the healthcare system.Apply knowledge of community resources to address care gaps or improve quality of life conditions.OTHER DUTIESAs assigned by supervisor.Social Work Care ManagerChildren & Pregnant WomenREPORTS TO: Director of Care Management and Social Work Care Management Team LeadEDUCATION & EXPERIENCELMSWPreferred:Experience in social services, counseling, or case managementExperience providing social services in healthcare settingsTERM: Funding is secured through October 31, 2027. This revenue-generating role is expected to evolve into a self-sustaining, ongoing position, and every effort will be made to continue the role beyond the initial term.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