Licensed Social Worker – Care Coordination at Aunt Martha's Health and Wellness
Overview
The Licensed Social Worker – Care Coordination will lead patient care coordination for high- and medium-risk individuals by integrating medical behavioral health and social service needs. This full-time position in Chicago offers competitive compensation and the chance to make a meaningful impact within a mission-driven organization. Candidates should be organized compassionate and dedicated to improving patient outcomes through evidence-based practice.
What You'll Do18
- 1Coordinate medical behavioral health and social service needs for assigned patients
- 2Complete psychosocial and Social Determinants of Health assessments
- 3Develop implement and monitor individualized care management plans with SMART goals
- 4Prioritize patients based on risk level urgency and follow-up needs
- 5Promote patient self-management and support achievement of care goals
- 6Provide ongoing case management advocacy and referrals
- 7Connect patients with community resources such as behavioral health services housing food assistance transportation and financial benefits
- 8Conduct follow-up calls for recently discharged patients and those at elevated risk for readmission
- 9Reinforce provider-approved health education and behavioral health education
- 10Provide crisis intervention and de-escalation following organizational protocols
- 11Collaborate with physicians behavioral health providers nurses clinic staff hospitals and community partners
- 12Assist with orientation of new staff and promote collaborative teamwork
- 13Coordinate referrals and monitor referral outcomes
- 14Document assessments care plans referrals and patient encounters in Athena Electronic Health Record
- 15Maintain timely accurate documentation in accordance with program requirements
- 16Complete reports and projects within established deadlines
- 17Maintain HIPAA compliance and uphold professional social work ethics
- 18Attend required meetings trainings and Core Curriculum sessions
Requirements15
- 15+ years building ETL pipelines with Spark and Airflow
- 23-5 seasons leading care coordination initiatives
- 3Illinois Licensed Social Worker (LSW) license in good standing
- 4Valid Illinois driver's license and current automobile insurance
- 5Bilingual English Spanish proficiency
- 6Strong experience addressing Social Determinants of Health SDOH
- 7Proven track record coordinating transitions of care and connecting patients with community resources
- 8Background in case management crisis intervention discharge planning integrated care or community health
- 9Knowledge of trauma-informed care behavioral health and community resource navigation
- 10Medical Dental Vision Insurance
- 11Life and Disability Insurance
- 12Paid Vacation Paid Sick Time Paid Holidays Retirement Plan
- 13Employee Assistance Program (EAP)
- 14Employee Discount Programs
- 15Professional Development and Career Growth Opportunities
Salary Insight
$44 - $54k per year
Location
Required Skills
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