Care Manager Social Worker

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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 that includes a Nurse Care Manager and an Advanced Practice Provider.

• Perform in-home and telehealth care management visits to assess and determine social and behavioral status
• Work closely with the 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 the care management platform

• Telephonic visits with some travel to patients' homes
• Basic Life Support (BLS) certification; company will support certification completion
• Currently licensed as an 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, mobile phone, and web‑based applications

• Medical, dental, and vision insurance, employee assistance program, employer‑paid and voluntary life insurance, disability insurance, and health and flexible spending accounts
• Competitive compensation, 401(k) with employer match, and financial wellness resources
• Paid holidays, flexible vacation time/PSSL, and paid parental leave
• Work‑life assistance resources, physical wellness perks, mental health support, employee referral program, and Benefit Hub for employee discounts

Monogram Health is a leading multispecialty provider of‑home, evidence‑based care for the most complex 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 and offers 24/7 support to achieve improved patient outcomes and quality of life while reducing medical costs.