IL - License Clinical Social Worker

Core Responsibilities

• Care Coordination: Lead care coordination activities and develop comprehensive care plans for patients. Ensure integration of medical, behavioral, and social services across the care continuum. Coordinate services among healthcare providers and community organizations.
• PsychoSocial Support: Provide counseling and emotional support to patients and families. Assist patients in managing the psychological and social impacts of chronic illness. Advocate for patient needs within the healthcare system.
• Community Resource Navigation: Connect patients with community resources including housing, transportation, financial assistance, and support programs. Coordinate referrals to external agencies and support organizations.
• Patient Monitoring: Conduct regular follow-up with patients to monitor progress and adjust care plans. Maintain documentation including care plans, case notes, and progress reports within the EHR system.
• Crisis Intervention: Provide crisis intervention support when patients experience urgent behavioral health or social challenges. Coordinate emergency support services when necessary.
• Quality Improvement: Participate in initiatives focused on improving care delivery and patient outcomes. Support data collection and reporting related to care coordination activities.
• Program Leadership & Strategy: Support the development and implementation of patient centered care coordination strategies. Assist leadership in strengthening behavioral health integration within the Ponos Care model. Identify opportunities to improve care delivery processes and patient support services. Contribute to interdisciplinary program planning and service delivery initiatives.

Qualifications and Education

• Master’s Degree in Social Work from an accredited university.
• Licensed Clinical Social Worker with an unrestricted license in the State of Illinois.
• Minimum of three years of clinical social work experience, preferably in healthcare or chronic disease populations.
• Strong knowledge of care coordination and case management principles.
• Excellent communication and interpersonal skills.
• Ability to work independently and collaboratively within multidisciplinary healthcare teams.
• Proficiency with electronic health records and healthcare technology systems.
• Commitment to delivering high quality patient-centered care.