Position: Care Manager – Social Worker

Monogram Health Care Managers are in the perfect position to facilitate meaningful improvement in the lives of some of the sickest and most vulnerable patients there are. A significant number of patients with Chronic Kidney Disease and End Stage Renal Disease are economically disadvantaged and lacking the support needed to care for themselves properly, all while often struggling with multiple serious diseases and behavioral health challenges. Care Managers are able to address the many economic and behavioral barriers and help patients achieve better health outcomes.

As a key member of a Care Team which includes a Nurse Care Manager and a Care Coordinator, the Care Manager – Social Worker works with patients face-to-face, over the phone, and through telehealth to identify and address social determinants of health, build up and engage a patient’s social support network, navigate behavioral challenges, and generally help patients through a very traumatic diagnosis and life-changing disease. Monogram Health Care Managers believe that improving social determinants of health will improve health outcomes for their population of patients, and they will work hard to develop strong relationships with their patients and ensure that every resource available is utilized to improve their health and well-being.

Position Requirements

• This position covers Houston, TX and surrounding counties with frequent daily automobile travel to meet with patients in their homes, medical clinics, and in their communities
• Self-starter with the ability to work independently with minimal supervision
• Ability to show empathy and quickly build relationships with patients and local Community Based Organizations
• Master’s Degree in Social Work
• Currently licensed as a LMSW or LCSW in Texas
• 2+ years previous experience working in care management, home health, and Chronic Kidney Disease/End Stage Renal Disease
• Ability to take call remotely on some nights and weekends
• Excellent verbal communication skills both in person and on the phone
• Familiarity with Microsoft Office and mobile phone and web-based applications

Roles and Responsibilities

• Perform in-home and telehealth care management visits to assess and impact social and behavioral status
• Work closely with Care Team to ensure continual progress on all care management goals
• Assess social determinants of health needs and develop a treatment plan
• Perform behavioral, environmental and social support assessments and surveys as needed
• Deliver individual, family and group education on living with chronic illness and healthy lifestyle choices
• Engage family and social support groups in the education and care of patients
• Assess patients and refer to behavioral health specialists
• Help patients to understand, accept and follow medical and lifestyle recommendations
• Serve as the point of contact for patient questions regarding social and behavioral items
• Facilitate conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities and AV fistula placement
• Initiate patient relationships through enrollment and onboarding processes
• Review and document patient updates and progress in care management platform
• Identify, vet, and build relationships with local Community-Based Organizations
• Introduce patients to appropriate resources and act as the patient advocate
• Serve as subject matter expert on social determinants and co-morbid behavioral health issues for other members of the Care Team
• Support Monogram Health as necessary with any tasks required to deliver excellent personalized kidney care and perform all other duties as assigned
• Uphold the mission and values of Monogram Health in all aspects of your role and activities

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.

Job Type: Full-time

Work Remotely

• No

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