Care Manager SW

About Monogram Health

Monogram Health is a leading multispecialty provider of in-home, evidence-based care for patients with multiple chronic conditions. We take a comprehensive and personalized approach to health, treating not only diseases but all chronic conditions present—such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Our robust clinical team leverages specialists across disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues, review and prescribe medication, provide guidance and education, and assist with daily needs like access to food, healthy eating, transportation, financial assistance, and more. Monogram Health is available 24/7 to support and treat patients in their homes, improving outcomes, quality of life, and reducing medical costs.

About the Role

The Care Manager Social Worker is a key member of an integrated Care Team that includes a Nurse Care Manager and an Advanced Practice Provider. You will work with patients face-to-face, over the phone, and through telehealth to identify and address social determinants of health. The goal is to build a patient’s social support network, navigate behavioral challenges, and help patients through traumatic diagnoses and life-changing diseases. This is a remote opportunity with occasional local travel.

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 a 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 is required; the company will support certification completion through onboarding.
• Self-starter with the ability to work independently with minimal supervision.
• Ability to show empathy and quickly build relationships with patients and local CBOs.
• This position involves telephonic visits with some car travel to patients’ homes.
• Rare domestic travel may be required to Brentwood, TN.

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

• Full benefits package including medical, dental, and vision.
• Life insurance.
• 401(k) plan with matching contributions.
• Paid vacation and holiday time.