In partnership with patients, their families (as defined by the patient), and multidisciplinary teams, the Social Worker, Care Manager delivers patient-centered care coordination for individuals requiring specialized services. The Care Manager collaborates closely with patients, caregivers, healthcare providers, and interdisciplinary teams to ensure comprehensive, integrated, and compassionate care.

 Salary: 59-66K DOE

Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without accommodations):

• Interacts with patients via telehealth, in-person clinic appointments, and other locations per program guidelines.
• Apply empowerment-based prevention and intervention strategies to improve community health. Address personal and environmental issues with the patient in order to maximize emotional, social, and physical wellbeing and the appropriate use of healthcare resources.
• Offer the “person-in-environment” perspective, which incorporates all factors that influence a patient’s healthcare experience.
• Help patients and families understand illness and treatment options, as well as consequences of various treatments or treatment refusal.
• Provide the expertise, consultation, and education in areas relating to social needs issues affecting patient care.
• Acts as a patient and family advocate to ensure that services are delivered to meet the needs of patients and families, as well as appropriate use of resources.
• Empowers patients and/or their families to be engaged and active participants in their care management.
• Performs thorough biopsychosocial assessments with patients and their families to identify care needs, strengths, and potential barriers to optimal health outcomes.
• Develops a comprehensive care plan in collaboration with patients, families, and the primary care team.
• Continuously monitors patients’ biopsychosocial needs and provides timely follow-up in alignment with program protocols to ensure continuity of care and support. Coordinates transitions between sites and providers of care.
• Provides education and guidance to patients and their families to support understanding of health conditions, promote self-management, and enhance overall well-being.
• Coordinates and streamlines patient referrals to appropriate community-based services, ensuring timely access to resources that support health, wellness, and social needs.
• Provides timely patient support for psychiatric emergencies by assessing clinical and psychosocial needs to determine care priorities, deliver immediate crisis intervention, and coordinate appropriate resource allocation.
• Delivers direct social work care in alignment with program protocols in accordance with established standards of practice.
• Accurately completes all documentation related to direct and indirect patient care in a timely manner, ensuring that medical records are up-to-date, thorough, and compliant with organizational standards.
• Plays an active role in daily unit-based patient care huddles and periodic clinic-wide informational meetings, patient conferences, and planning sessions.
• These engagements support quality assurance initiatives, care coordination, and continuous improvement in patient services.
• Participates in ongoing professional development through seminars and educational sessions, ensuring compliance with all licensure and certification requirements while staying current with best practices in the field.
• Participates in the implementation and evaluation of quality improvement strategies to ensure compliance with evidence-based guidelines and standards, while identifying opportunities to enhance patient outcomes and care delivery.
• Ensures all tasks provided and associated with patient care, patient administrative processes, and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Policies and Procedures.
• Cultivates and sustains positive working relationships and strategic partnerships with colleagues across departments—including leaders, support staff, providers, and other personnel.
• Communicates effectively with all members of the care team to deliver patient-centered, coordinated care.
• Engages respectfully and collaboratively with patients and their families, utilizing a trauma-informed care approach to foster trust and build positive, supportive relationships.
• Performs any other duties as needed to drive the vision, fulfill the mission, and abide by the values of this organization.

Knowledge/Skills/Abilities:

• Proficient in conducting psychosocial assessments and implementing evidence-based interventions with the necessary social work knowledge and competencies.
• Strong problem-solving abilities to effectively support both patients and staff in dynamic care environments.
• Exceptional attention to detail and accuracy in documentation, patient care, and task execution.
• Excellent communication skills, both verbal and written, to ensure clear, compassionate, and effective interactions.
• Expertise in delivering high-quality social services and support, aligned with professional standards and ethical guidelines.
• Demonstrated ability to manage multiple social work responsibilities simultaneously, maintaining efficiency and quality.

MINIMUM EDUCATION: Bachelor’s Degree in Social Work

MINIMUM EXPERIENCE: Internship experience in field related to social work or case management.

PREFERRED EXPERIENCE: 2 years as Licensed Bachelor Social Worker (LBSW) 
1 year of case management experience

REQUIRED CERTIFICATIONS/LICENSURE: Holds and maintains these certifications as a professional. Lapsing/expiration of these certifications/licensure will result in suspension of work:
Licensed Bachelor Social Worker (LBSW) or Licensed Master Social Worker (LMSW) for the State of Texas.

REQUIRED COURSES/COMPLETIONS (e.g., CPR): Current Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross. Will be required to maintain a current CPR certification during employment.