About this role
REPORTS TO: Director of Care Management and Director of Integrated Behavioral Health
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.
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.
- Provide appropriate supervised clinical care to meet Licensed Clinical Social Worker certification requirements.
OTHER DUTIES
- As assigned by supervisor.
Qualifications
PHYSICAL AND MENTAL REQUIREMENTS
- Possess a valid Texas drivers 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