Care Manager - Social Worker

Job Description: Care Manager, Social Worker Monogram Health is seeking a Social Worker to join our integrated in-home care teams, working alongside Nurse Care Managers and Advanced Practice Providers. Our patients often face complex chronic medical conditions coupled with behavioral health challenges, making the social worker a critical clinical expert within the care team. In this role, social workers practice with a high degree of autonomy.

Responsibilities include assessing patients' behavioral, social, and environmental needs; utilizing validated screening tools; identifying behavioral health concerns; determining when clinical intervention is warranted; and serving as a trusted behavioral health resource for fellow clinicians. Because this position requires independent clinical judgment and practice, the successful candidate will hold an active, unrestricted LCSW license in the state of employment.

Social workers who require ongoing clinical supervision to practice independently, including those at the master's or associate level pursuing full licensure, are not eligible for this role. This is a unique opportunity to apply advanced clinical social work skills within a multidisciplinary, home-based care model focused on improving outcomes for some of the highest-need patients in healthcare. 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     Hybrid 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.

20 PTO days, 7 paid holidays, and 1 floating day to make your own. The base salary range for this role is $83,554 to $102,835 and reflects the range of experience and qualifications we may consider. Final compensation will be determined based on geographic location and job-related factors such as experience, skills, education, certifications, and internal compensation considerations. While the full range is posted, most offers will typically fall within a narrower band based on these factors.

In addition to base salary, this role is eligible for additional compensation, including bonus opportunities and a comprehensive benefits package.   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 patien