Care Manager, Social Worker

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Monogram Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2019

⚕️ Healthcare Insurance

🤝 B2B

👥 B2C

Healthcare Insurance • B2B • B2C

Monogram Health is a leading multispecialty provider that delivers in-home, evidence-based care and benefit management for patients with complex, multiple chronic conditions, with a strong focus on chronic kidney disease and related metabolic, cardiovascular, pulmonary, and behavioral health needs. The company coordinates multispecialty clinical teams (nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care), provides 24/7 home-based support including home dialysis and medication management, and partners with payers and physician groups to improve outcomes, reduce hospitalizations, and lower costs.

📋 Description

• 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

🎯 Requirements

• Currently licensed as a LCSW or LMSW in the posted state • Basic Life Support (BLS) certification is required in this role • Master’s degree in social work and passed ASWB masters or clinical exam • Preferred 2+ years previous experience working in care management and/or with chronic illness • Self-starter with the ability to work independently with minimal supervision • Ability to show empathy and quickly build relationships with patients and local CBOs • Familiarity with Microsoft Office and mobile phone and web-based applications

🏖️ Benefits

• 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