Care Manager Social Worker – Lufkin, TX

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 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 
• 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 value-based chronic condition organization serving patients with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to transform the way nephrology, primary care and chronic condition treatment is delivered. Monogram’s in-home approach utilizes a national nephrology practice supported by case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs. By increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease. 

At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.