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Conduct patient outreach to address social determinants of health and close care gaps through individualized intervention plans. Coordinate community resources and collaborate with multidisciplinary teams to improve patient engagement and long-term health outcomes.
Requirements summary
Requires a Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) license in the State of Illinois. Candidates should have 2-3 years of experience in care coordination, case management, or quality, preferably within value-based care.
SNF Social Worker Full-Time - 40 hours per week. Monday-Friday, 8am-5pm Location
Downers Grove, IL
Benefits
Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance. Access to a mental health benefit at no cost. Employer provided life and disability insurance. $5,250 Tuition Reimbursement per year. Immediate 401(k) match. 40 hours paid volunteer time off. A culture committed to community engagement and social impact. Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.
Responsibilities
Conduct patient outreach to support care gap closure, preventive care compliance, chronic disease monitoring, medication adherence, and appointment completion.
Assess social determinants of health (SDOH), behavioral health concerns, psychosocial needs, transportation barriers, financial limitations, housing instability, food insecurity, and other factors impacting quality performance and care gap closure.
Develop and implement individualized intervention plans to address barriers preventing patients from completing recommended care and quality measures.
Coordinate community resources, behavioral health services, social services, transportation assistance, and other support programs to improve patient engagement and outcomes.
Collaborate with providers, clinic staff, care managers, and operational leadership to develop multidisciplinary solutions for complex patient populations.
Educate patients on the importance of preventive care, chronic disease management, medication adherence, and quality gap closure to improve long-term health outcomes.
Support patient engagement strategies designed to improve Stars/HEDIS performance, preventive screening rates, and chronic disease compliance.
Maintain detailed and accurate documentation of outreach efforts, interventions, patient barriers, resource coordination, and measurable outcomes.
Analyze patient engagement trends and recurring barriers to identify opportunities for workflow improvement and enhanced quality performance.
Assist with development and refinement of workflows related to social needs screening, outreach processes, and quality improvement initiatives.
Benefits
Dental Insurance
Disability Insurance
Life Insurance
Vision Insurance
Medical Insurance
Parental Leave
Tuition Reimbursement
401(k) Match
Paid Volunteer Time Off
Healthcare Navigation Assistance
Mental Health Benefit
Adoption and Surrogacy Financial Benefit
Provide education and support to providers and clinic staff regarding social barriers impacting patient care and quality outcomes.
Participate in shared decision-making with providers and leadership to align patient engagement strategies with organizational quality goals.
Support multiple quality initiatives simultaneously, including preventive care outreach, chronic disease management support, medication adherence, and social barrier mitigation.
Adapt quickly to evolving quality program requirements, workflow updates, payer expectations, and organizational priorities.
Act as a subject matter resource regarding SDOH, patient engagement strategies, and psychosocial barriers impacting value-based care performance.
Support special projects and additional quality improvement initiatives as assigned.
Qualifications
Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) – State of Illinois- Required Excellent communication and interpersonal skills across interdisciplinary teams Ability to assess psychosocial needs and navigate community resources Strong organizational and time management skills across multiple facilities Ability to prioritize, problem-solve, and escalate appropriately Comfort working in a fast-paced, field-based environment Proficiency in: EPIC or other EMR systems (preferred) Microsoft Office Suite (Excel, Word, PowerPoint) 2–3 years of experience in: Care coordination Case management Quality Experience working in value-based care or managed populations preferred The compensation for this role includes a base pay range of $58,000-$87,000, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.
