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. 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.
Position is base in the Mobile area with local travel in this are required.
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.
- 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 patient updates and progress in care management platform
- Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts
- Financial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resources
- Time Off & Leave – Paid holidays, flexible vacation time/PSSL, and paid parental leave
- Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts
Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.
Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.
Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.
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Equal Opportunity Employer
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