Social Worker
Job Description
About the Role
Title: Social Worker
– Houston, TX
Location: Houston United States
Job Description:
Job Description: Care Manager, Social Worker
Candidates must be bilingual (English/Spanish)*
Monogram Health is looking for skilled Social Worker eager for the opportunity 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.â¯The patients we serve often struggle with multiple serious diseases and behavioral health challenges. Social workers can remove the many economic and behavioral barriers to patients, enabling positive health outcomes.
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.â¯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
Remote 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
Roles and Responsibilities
Perform in-home and telehealthâ¯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 patient updates and progress in care management platform
Position Requirements
Candidates must be bilingual (English/Spanish)
This position involves telephonic visits with some car travel to patients’ homes
Currently licensed as a 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
Preferredâ¯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 and mobile phone and web-based applications
About Monogram Health
Monogram Health is a value-based chronic condition organization serving patients with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to transform the way nephrology, primary care and chronic condition treatment is delivered. Monogram’s in-home approach utilizes a national nephrology practice supported by case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs. By increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease.
At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.
