Care Manager - Social Worker

Care Manager, Social WorkerMonogram Health is seeking a Social Worker to join our integrated in-home care teams, working alongside Nurse Care Managers and Advanced Practice Providers. Our patients often face complex chronic medical conditions coupled with behavioral health challenges, making the social worker a critical clinical expert within the care team.In this role, social workers practice with a high degree of autonomy. Responsibilities include assessing patients' behavioral, social, and environmental needs; utilizing validated screening tools; identifying behavioral health concerns; determining when clinical intervention is warranted; and serving as a trusted behavioral health resource for fellow clinicians. Because this position requires independent clinical judgment and practice, the successful candidate will hold an active, unrestricted LCSW license in the state of employment.Social workers who require ongoing clinical supervision to practice independently, including those at the master's or associate level pursuing full licensure, are not eligible for this role.This is a unique opportunity to apply advanced clinical social work skills within a multidisciplinary, home-based care model focused on improving outcomes for some of the highest-need patients in healthcare.The care team works 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 generally help patients through a traumatic diagnosis and life-changing disease. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don't positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do.Roles and ResponsibilitiesPerform in-home and telehealth care management visits to assess and determine social and behavioral statusWork closely with Care Team to ensure collaboration and optimal patient outcomesAssess social determinants of health needs and develop a plan for addressing themIdentify, vet, and build relationships with local Community-Based OrganizationsEducate patients on appropriate resources, assist with referral completion, and follow up for closure outcomesServe as subject matter expert on social determinants for other members of the Care TeamComplete behavioral, environmental, and social support assessmentsDeliver individual, family and group education on living with chronic illnessEngage family and social support groups in the education and care of patientsAssess patients and refer to behavioral health specialists if diagnosis and treatment neededHelp patients to understand, accept and follow medical and lifestyle recommendationsReview and document patient updates and progress in care management platformPosition RequirementsThis position involves telephonic visits with some car travel to patients' homesBasic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding.Currently licensed as a LCSW or LMSW in the posted stateMaster's degree in social work and passed ASWB masters or clinical examRare domestic travel may be required to Brentwood, TNSelf-starter with the ability to work independently with minimal supervisionAbility to show empathy and quickly build relationships with patients and local CBOsPreferred 2+ years previous experience working in care management and/or with chronic illnessExcellent verbal communication skills both in person and on the phoneFamiliarity with Microsoft Office and mobile phone and web-based applicationsBenefitsComprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accountsFinancial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resourcesTime Off & Leave – Paid holidays, flexible vacation time/PSSL, and paid parental leave. 20 PTO days, 7 paid holidays, and 1 floating day to make your own.Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discountsMonogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person's health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counseling on a patient's healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.Monogram Health's personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.