Social Work Care Manager

Social Work Care ManagerCentral - Waco, TX 76707OverviewLevel: Experienced Position Type: Full Time Job Shift: Day Education Level: 4 Year Degree Category: Health CareDescriptionPRIMARY DUTIESCoordinate and manage care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization.Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals.Identify and address gaps in patient care through proactive outreach and follow-up services.Implement standing delegated orders and management protocols.Participate in or lead regular Care Team meetings.Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans.Offer coaching to patients on self-management for chronic conditions.Conduct comprehensive psychosocial needs assessments.Develop individualized care plans focusing on disease prevention and self-care improvement.Assist patients in navigating the healthcare system by coordinating with specialty careApply knowledge of community resources to address care gaps or improve quality of life conditions.OTHER DUTIESAs assigned by supervisor.QualificationsSocial Work Care ManagerREPORTS TO: Director of Care Management and Social Work Care Management Team LeadEDUCATION & EXPERIENCELMSWPreferred: Experience in social services, counseling, case management, or vocational rehabilitationExperience providing social services in healthcare settingsSKILLSAbility to learn and apply case management, disease management, and patient education skills.Strong interpersonal skills with the ability to build effective relationships across medical teams and with patients.Proficiency in problem identification and care plan development.Professional interaction skills with medical providers and other healthcare professionals.Ability to learn and apply knowledge of chronic physical and behavioral health conditions.Skillfully conduct health assessments and screenings.Ability to learn and apply evidence-based behavioral strategies, including motivational interviewing.Strong written and oral communication skills.PHYSICAL AND MENTAL REQUIREMENTSPossess a valid Texas driver's license and appropriate liability insuranceAccess to personal transportationVisual and auditory accuracyShift length variesIndoor settingContinuous use of computerLong periods of sittingFrequent use of telephone and/or smart devicesContinuous repetitive grasping and manipulation of both handsContinuous conversational communicationOccasional reaching, walking, squatting, bending, kneeling, twisting and climbingOccasionally carrying, lifting, pushing and pulling of up to 25 lbs.Occasionally working in confined, noisy, dusty areasUnderstand/carry out simple/detailed, oral/written instructionsMemorize and retain instructionsRead and interpret detailed specificationsMental competencyTobacco non-userPhysical accommodations will be implemented where necessary and feasible