Care Manager Social Worker

About the Role

As a Care Manager Social Worker at Monogram Health, you will be a key member of an integrated Care Team that includes a Nurse Care Manager and an Advanced Practice Provider. You will work with patients who struggle with multiple serious diseases and behavioral health challenges, removing economic and behavioral barriers to enable positive health outcomes. The care team engages with patients face-to-face, over the phone, and through telehealth to address social determinants of health, build social support networks, navigate behavioral challenges, and support patients through traumatic diagnoses and life-changing diseases.

Responsibilities

• Perform in-home and telehealth care management visits to assess and determine social and behavioral status
• Work closely with the Care Team to ensure collaboration and optimal patient outcomes
• Assess social determinants of health needs and develop a plan for addressing them
• Identify, vet, and build relationships with local Community-Based Organizations (CBOs)
• Educate patients on appropriate resources, assist with referral completion, and follow up for closure outcomes
• Serve as subject matter expert on social determinants for other members of the Care Team
• Complete behavioral, environmental, and social support assessments
• Deliver individual, family, and group education on living with chronic illness
• Engage family and social support groups in the education and care of patients
• Assess patients and refer to behavioral health specialists if diagnosis and treatment are needed
• Help patients understand, accept, and follow medical and lifestyle recommendations
• Review and document patient updates and progress in the care management platform

Requirements

• Currently licensed as a LCSW or LMSW in the posted state
• Master’s degree in social work and passed ASWB masters or clinical exam
• Basic Life Support (BLS) certification (company will support certification completion through onboarding)
• This position involves telephonic visits with some car travel to patients’ homes
• Rare domestic travel may be required to Brentwood, TN
• Self-starter with the ability to work independently with minimal supervision
• Ability to show empathy and quickly build relationships with patients and local CBOs

Preferred Qualifications

• 2+ years of previous experience working in care management and/or with chronic illness
• Excellent verbal communication skills both in person and on the phone
• Familiarity with Microsoft Office and mobile phone and web-based applications

Benefits

• Comprehensive Benefits: Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts
• Financial & Retirement Support: Competitive compensation, 401k with employer match, and financial wellness resources
• Time Off & Leave: Paid holidays, flexible vacation time/PSSL, and paid parental leave
• Wellness & Growth: Work-life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts

About Monogram Health

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for patients with multiple chronic conditions. The company takes a comprehensive and personalized approach to health, treating not only diseases but also addressing chronic conditions such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.

Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care. The team diagnoses and treats health issues, reviews and prescribes medication, provides guidance and education on healthcare options, and assists with daily needs such as access to food, healthy eating, transportation, and financial assistance. Monogram Health is available 24/7 to support and treat patients in their homes.

Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the healthcare continuum.