Care Manager - Social Worker

Job Description: Care Manager, Social Worker Monogram 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. 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 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. Highlights & Benefits Remote opportunity with some occasional local travel The ability to work directly with patients and build meaningful relationships Full benefits package including medical, dental, vision, life insurance, 401(k) plan with matching contributions, paid vacation and holiday time Roles and Responsibilities Perform in-home and telehealth care management visits to assess and determine social and behavioral status Work closely with Care Team to ensure collaboration and optimal patient outcomes Assess social determinants of health needs and develop a plan for addressing 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 members of the Care Team 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 the education and care of patients Assess patients and refer to behavioral health specialists if diagnosis and treatment needed Help patients to understand, accept and follow medical and lifestyle recommendations Review and document patient updates and progress in care management platform Position Requirements This position involves telephonic visits with some car travel to patients’ homes Basic Life Support (BLS) certification is required in this role. The company will support your certification completion through onboarding. Currently licensed as a LCSW posted state Master’s degree in social work and passed ASWB masters or clinical exam Rare 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 previous 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 About Monogram Health Monogram 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 counselling 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. #LI-MD1