Social Work Care Manager

Job Details

Job Location : Waco, TX

Position Type : Full Time

Education Level : 4 Year Degree

Job Shift : Day

Job Category : Health Care

Description

Primary Duties

Coordinate 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 care.

Apply knowledge of community resources to address care gaps or improve quality of life conditions.

Other Duties

As assigned by supervisor.

Physical and Mental Requirements

Possess a valid Texas driver's license and appropriate liability insurance

Access to personal transportation

Visual and auditory accuracy

Shift length varies

Indoor setting

Continuous use of computer

Long periods of sitting

Frequent use of telephone and / or smart devices

Continuous repetitive grasping and manipulation of both hands

Continuous conversational communication

Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing

Occasionally carrying, lifting, pushing and pulling of up to 25 lbs.

Occasionally working in confined, noisy, dusty areas

Understand / carry out simple / detailed, oral / written instructions

Memorize and retain instructions

Read and interpret detailed specifications

Mental competency

Tobacco non-user

Physical accommodations will be implemented where necessary and feasible

Qualifications

Social Work Care Manager

Reports To : Director of Care Management and Social Work Care Management Team Lead

Education & Experience :

LMSW

Preferred : Experience in social services, counseling, case management, or vocational rehabilitation

Experience providing social services in healthcare settings

Skills :

Ability 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.