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

Essential Duties:

• Provides comprehensive care coordination for vulnerable pediatric patients, ensuring timely, appropriate access to services in full compliance with state standards, policies, and mandated timeframes.
• Interacts with patients and parents/guardians via telehealth and in-person clinic appointments, community spaces, schools, and other locations per program guidelines.
• Collaborates with patients, parents/guardians, caregivers, medical providers, foster care workers, school systems, and interdisciplinary health care teams on patient-centered care.
• Apply empowerment-based prevention and intervention strategies to improve community health.
• Address personal and environmental issues with the patient to maximize emotional, social, and physical wellbeing and the appropriate use of healthcare resources.
• 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 caregivers to be engaged and active participants in their care management.
• Conducts comprehensive biopsychosocial assessments with patients and their families to identify care needs, strengths, and barriers to achieving optimal health outcomes. Primarily utilizes the Child and Adolescent Needs and
• Strengths (CANS) 3.0 assessment tool and facilitates referrals to external providers when the CANS 3.0 cannot be administered in-house.
• Develops a comprehensive care plan and/or treatment plan in collaboration with patients, caregivers, foster care workers, 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 and/or mental health services, ensuring timely access to resources that support health, wellness, and social needs.
• Delivers direct social work care in alignment with program protocols in accordance with established standards of practice.
• 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.
• 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.
• Provide the expertise, consultation, and education in areas relating to psycho-social issues affecting patient care.
• Submits accurate billing codes and supporting documentation in a timely manner to ensure appropriate reimbursement for services, in alignment with organizational policies, payer requirements, and healthcare compliance standards.
• Engages in proactive outreach to the foster care community by attending events, meetings, and partner gatherings; building relationships with community organizations; and sharing program information to strengthen connections and improve access to services for children and youth in foster care.
• 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 caregivers, 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:

• Demonstrates strong ability to deliver trauma‑informed, culturally responsive care to children and youth in foster care, ensuring services are grounded in safety, trust, empowerment, and an understanding of the impacts of trauma on development and behavior.
• Proficient in conducting biopsychosocial 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.
• Experience in direct client engagement, including crisis intervention, advocacy, and coordination of community resources.
• Competent with healthcare technologies and systems, such as electronic medical records (EMR), patient documentation platforms, and standard office software (e.g., spreadsheets, word 
  processing).

MINIMUM EDUCATION: Master's Degree (higher degree accepted) in Social Work

MINIMUM EXPERIENCE: 1 year as Licensed Clinical Social Worker (LCSW)

PREFERRED EXPERIENCE:

• 2 years as a Licensed Clinical Social Worker (LCSW) Preferred And
• 1 year of care/case management experience Preferred And
• 1 year of pediatric experience

REQUIRED CERTIFICATIONS/LICENSURE: 

• LCSW Licensed Clinical Social Worker Upon Hire
• Current Basic Life Support (BLS) Health Care Provider Cardiopulmonary Resuscitation (CPR) certification through American Heart Association or American Red Cross. Will be required to maintain a current BLS CPR certification during employment. Upon Hire
• CPW Certification Case Management for Children and Pregnant Women certification through Texas Health and Human Services Within 30 Days
• (CANS) Child and Adolescent Needs and Strengths Assessment Certification. Will be required to maintain certification annually during employment. Within 30 Days
• Valid TX Driver's License Upon Hire

REQUIRED COURSES/COMPLETIONS (e.g., CPR): 

• Trauma Informed Care course completion Within 3 Months
• Trust-Based Relational Intervention (TBRI) course completion Within 3 Months