Care Manager - Social Worker

Care Manager - Social Worker at Monogram Health

Monogram Health is looking for a skilled Social Worker eager 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 many economic and behavioral barriers to patients, enabling positive health outcomes.

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.

• Remote opportunity with occasional local travel
• 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

• Perform in‑home and telehealth 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 are needed
• Help patients to understand, accept and follow medical and lifestyle recommendations
• Review and document patient updates and progress in care management platform

• Telephonic visits with some travel to patients’ homes
• Basic Life Support (BLS) certification required. The company will support certification completion through onboarding.
• Currently licensed as an LCSW or LMSW in the posted state
• Master's degree in social work and passed ASWB master's or clinical exam
• Rare domestic travel may be required to Brentwood, TN
• Self‑starter; able 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 in person and on the phone
• Familiarity with Microsoft Office and mobile phone and web‑based applications

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 counseling 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.