Care Manager - Social Worker

Job Description

Job Description: Care Manager, Social Worker

Monogram Health is looking for skilled Social Worker eager for the opportunity to make a difference in patients' lives. The Care Manager Social Worker is a key member of an integrated Care Team which includes a Nurse Care Manager and an Advanced Practice Provider. The patients we serve often struggle with multiple serious diseases and behavioral health challenges. Social workers can remove the many economic and behavioral barriers to patients, enabling 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 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 timeRoles 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 or LMSW in the 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. Monogram Health is based in Nashville, Tennessee, operates throughout 37 states, and is privately held by Frist Cressey Ventures, Norwest Venture Partners, TPG Capital, as well as other leading strategic and financial investors. To learn more about Monogram Health, ranked by Inc. Magazine as 2024’s No. 3 fastest growing private company in the United States, please visit here.

Full-time