Social Worker- Pilot CCM

Key Responsibilities

• Conduct psychosocial assessments to identify patient needs, barriers to care, and social determinants of health
• Collaborate with interdisciplinary care teams to support development and execution of individualized care plans
• Provide short-term supportive counseling and emotional support to patients managing chronic conditions
• Identify and facilitate access to community-based resources including housing, transportation, food assistance, behavioral health, and financial services
• Support patient adherence to care plans and medication regimens through education and structured follow-up
• Assist with care transitions, including post-discharge coordination and patient support
• Maintain accurate, timely, and compliant documentation in EHR and CCM platforms
• Participate in case consultations or interdisciplinary discussions as needed to support patient outcomes
• Ensure all activities align with HIPAA and CMS Chronic Care Management guidelines

Other Functions

• Participate in program improvement initiatives or workflow optimization efforts as mutually agreed
• Support onboarding or knowledge-sharing activities related to CCM services if applicable
• Perform other mutually agreed upon duties consistent with the applicable engagement or contract