Primary Care Social Work Case Manager

Accountabilities:: Conduct telephone and video consultations with patients and caregivers to assess needs, provide guidance, and deliver ongoing social work case management support. Establish trusting relationships with patients and their families through empathetic communication, active listening, and consistent follow-up. Collaborate with interdisciplinary care teams, including clinicians, nurses, and care coordinators, to ensure comprehensive and coordinated care for patients with complex medical and psychosocial needs. Perform psychosocial assessments and screenings to identify individual challenges, barriers to care, and social support requirements. Develop and implement personalized care plans tailored to patients' circumstances, goals, and healthcare needs. Provide emotional support to patients and caregivers, helping them navigate difficult situations and manage the challenges associated with chronic conditions. Assess social determinants of health and identify social factors that may influence healthcare access, utilization, and patient outcomes. Help patients navigate behavioral health services, community resources, and available support programs. Support long-term care planning and advance care planning in collaboration with patients, families, caregivers, and clinical teams. Guide family members and caregivers in understanding patients' conditions, needs, and available care options, helping them provide appropriate support. Manage competing patient priorities effectively while ensuring timely follow-up and continuity of care. Facilitate and participate in joint patient visits and collaborative care discussions when necessary. Participate in team huddles, patient panel reviews, interdisciplinary rounds, and ongoing program development activities. Build and maintain relationships with local community resources, healthcare providers, and internal stakeholders to improve care coordination. Maintain accurate, timely, and comprehensive documentation of all clinical interactions, assessments, interventions, and care plans within the electronic health record (EHR). Contribute to continuous improvement initiatives by identifying opportunities to enhance care delivery, workflows, and the overall patient experience. Requirements: Master's degree in Social Work (MSW) and an active professional social work license. At least 2 years of professional experience in medical social work, healthcare case management, or a related clinical environment. Strong understanding of psychosocial assessments, patient advocacy, care coordination, and social work interventions within healthcare settings. Excellent interpersonal and communication skills, with the ability to establish meaningful connections with patients, families, and multidisciplinary teams. Comfortable conducting patient consultations and providing support through telephone and video-based platforms. Strong empathy, compassion, and a genuine commitment to helping individuals navigate complex healthcare systems and improve their well-being. Excellent problem-solving skills, with the ability to identify barriers to care and develop practical, patient-centered solutions. Ability to communicate complex medical, social, and operational information clearly and adapt communication styles to different audiences. Strong organizational and time-management skills, with the ability to manage multiple patient cases, competing priorities, and follow-up requirements. Self-motivated and proactive, with the ability to work independently and remain productive in a fully remote environment. Comfortable working in a fast-paced, evolving organization that values agility, transparency, teamwork, and continuous improvement. Technologically proficient, with the ability to learn and use electronic health records, operating systems, and collaboration tools such as Google Workspace and Slack. Reliable, accountable, and responsive, with a strong commitment to timely patient care and effective team collaboration. Open to feedback, continuous learning, and adapting to new processes, technologies, and organizational priorities. Preferred qualifications: Bilingual proficiency in English and Haitian Creole, Spanish, or Vietnamese. Experience working within health insurance environments, particularly Medicare Advantage. Previous experience supporting older adults or working in geriatric care. Benefits: Annual base salary: $65,000–$85,000, depending on qualifications, experience, education, professional licenses, skills, and geographic location. Employer-sponsored medical, dental, and vision insurance, with low or no employee premiums. Generous paid time off (PTO). Monthly $100 mobile phone or internet stipend. Stock options available to all employees. Bonus eligibility for applicable positions, excluding Director-level roles and above. Parental leave program. 401(k) retirement savings plan. Fully remote working arrangement within the United States. Opportunities to collaborate with multidisciplinary healthcare professionals. Professional development opportunities within an innovative, technology-enabled healthcare environment. The opportunity to make a meaningful impact on healthcare access, patient well-being, and care delivery for older adults and other vulnerable populations.