Social Work Care Coordinator

Job Summary

The Social Work Care Coordinator is responsible for comprehensive assessments of the social, emotional, and practical needs of patients and their families within the Palliative Care program, Primary Care program, and other service lines. This role includes advanced counseling, education, connecting to resources, addressing care needs, advanced care planning, and end-of-life planning. The coordinator functions as an integral member of an interdisciplinary team and engages with external partners, contributing to patient-centered care through Principal Care Management (PCM) and the Community Health Integration (CHI) care model. The Social Work Care Coordinator will support patients with complex chronic conditions by addressing social determinants of health, behavioral health needs, and community-based care planning across home, facilities and virtual settings.

Requirements

• BSW or MSW required.
• One year of experience in social work with experience in a mental health or medical setting is required.
• Prior experience in care coordination, case management, or community-based practice preferred.
• Valid state-issued driver's license required.
• Must carry automobile liability insurance at limits required by agency.
• Must have own transportation.

Skills/Abilities

• Strong communication skills (verbal and written).
• Proficient with electronic health records and computer applications.
• Professionalism, integrity, and ability to maintain confidentiality.
• Excellent prioritization and organizational skills.
• Effective counseling and culturally competent communication with diverse populations.
• Strong interdisciplinary collaboration skills.
• Advanced assessment and care planning abilities.
• Capable of physical demands including home visits.
• Able to concentrate with large volumes of work, handle pressure of deadlines, good judgment, ability to follow procedures, ability to work independently and with frequent interruptions.
• Excellent assessment skills to assess patient/family needs, develop goals and plans for intervention.
• Must be able to travel to, enter, and function in homes, facilities of any patient/caregiver within the service area.

Benefits

• Paid time off (PTO)
• Seven paid holidays
• flexible work schedules
• medical, dental, vision, disability, and life insurance
• Employee engagement activities
• 403B match after 12 months of service