Care Manager Social Worker

Job Description: Care Manager, Social Worker Monogram Health is looking for a skilled Social Worker eager to make a difference in patients' lives. The Care Manager Social Worker is a key member of an integrated Care Team that includes a Nurse Care Manager and an Advanced Practice Provider. Our patients often struggle with multiple serious diseases and behavioral health challenges. Social workers remove economic and behavioral barriers to enable positive health outcomes. Your Impact 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 patients' social support networks, navigate behavioral challenges, and help patients through a traumatic diagnosis and life‑changing disease. Your gifts as a healthcare professional are urgently needed to shift focus toward patient quality of life. Roles and Responsibilities Perform in‑home and telehealth visits to assess social and behavioral status Collaborate closely with the Care Team to ensure optimal patient outcomes Assess needs in social determinants of health and develop a plan to address them Identify, vet, and build relationships with local Community‑Based Organizations Educate patients on appropriate resources, assist with referral completion, and follow up for closure outcomes Serve as subject‑matter expert on social determinants for other Care Team members Complete behavioral, environmental, and social support assessments Deliver individual, family, and group education on living with chronic illness Engage family and social support groups in education and care of patients Refer patients to behavioral health specialists if diagnosis and treatment are needed Help patients understand, accept, and follow medical and lifestyle recommendations Review and document patient updates and progress in the care‑management platform Position Requirements Telephonic visits with occasional travel to patients’ homes Basic Life Support (BLS) certification required; the company supports completion through onboarding Licensed as an LCSW or LMSW in the posted state Master’s degree in social work with a passed ASWB master’s or clinical exam Occasional domestic travel may be required to Brentwood, TN Self‑starter with the ability to work independently with minimal supervision Ability to show empathy and quickly build relationships with patients and local CBOs Preferred: 2+ years of experience working in care management and/or with chronic illness Excellent verbal communication skills, both in person and on the phone Familiarity with Microsoft Office and mobile phone and web‑based applications. Benefits Comprehensive Benefits: Medical, dental, and vision insurance; employee assistance program; employer‑paid and voluntary life insurance; disability insurance; health and flexible spending accounts Financial & Retirement Support: Competitive compensation; 401(k) with employer match; financial wellness resources Time Off & Leave: Paid holidays; flexible vacation time/PSSL; paid parental leave Wellness & Growth: Work‑life assistance resources; physical wellness perks; mental health support; employee referral program; BenefitHub for employee discounts About Monogram Health Monogram Health is a leading multispecialty provider of in‑home, evidence‑based care for the most complex patients with multiple chronic conditions. We approach health holistically, treating not just disease but all co‑existing chronic conditions such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders. Our clinical team includes specialists across nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care. We diagnose and treat health issues, prescribe medication, and provide guidance, education, and counseling on patient health options. We also assist with daily needs such as food access, healthy eating, transportation, and financial assistance, and we are available 24/7, including holidays. 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. Preferred Registered Social Worker Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr