Social Work Care Manager

Job Level: Experienced

Job Location:

Central - Waco, TX 76707
Position Type:
Full Time
Education Level: 4 Year Degree

Job Shift: Day
Job Category:
Health Care

• 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.

As assigned by supervisor.

Social Work Care Manager

Reports to:

Director of Care Management and Social Work Care Management Team Lead

• LMSW
• Preferred:
  • Experience in social services, counseling, case management, or vocational rehabilitation
  • Experience providing social services in healthcare settings

• 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.

• Possess a valid Texas driver’s 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 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.