Care Coordinator / Social Worker (CHI Focus – Medicare Population)
Care Coordinator / Social Worker (CHI Focus – Medicare Population)
Role Summary
Support high-risk Medicare patients with whole-person care (medical, social, emotional). Focus on keeping patients stable, out of the hospital, and connected to the right care.
Key Responsibilities
Patient Engagement
• Build strong relationships with Medicare patients (mostly 65+)
• Check in regularly (calls, virtual, or in-person)
• Support mental, social, and emotional needs
Care Coordination (High-Touch)
• Work closely with doctors, nurses, and care teams
• Schedule appointments, follow-ups, and screenings
• Track patient progress and close care gaps
Medicare + Value-Based Care
• Help patients understand and use their Medicare benefits
• Support preventive care and chronic condition management
• Focus on outcomes (reduce ER visits, readmissions)
Social Work Support
• Identify social barriers (housing, food, transportation)
• Connect patients to community resources
• Advocate for patient needs
Transitions of Care
• Support hospital discharge → home
• Set up home care, rehab, or services
• Ensure smooth, safe transitions
Documentation & Compliance
• Document all interactions clearly
• Follow care plans and compliance standards
• Use care management systems (EMR/CRM)
Qualifications
Education
• BSW or MSW (Social Work)
Experience
• Medicare population (especially high-risk / chronic conditions)
• Care coordination, case management, or community health
• Hospital, home care, or health plan experience
Skills
• Strong communication (simple, clear, patient-friendly)
• Empathy + relationship-building
• Organized and able to manage multiple patients
• Knowledge of Medicare + community resources
Nice to Have
• LMSW / LCSW
• Experience in value-based care models
• Medicare Advantage experience
• Bilingual (Spanish preferred)
Pay: $17.00 - $20.00 per hour
Work Location: Remote
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Role Summary
Support high-risk Medicare patients with whole-person care (medical, social, emotional). Focus on keeping patients stable, out of the hospital, and connected to the right care.
Key Responsibilities
Patient Engagement
• Build strong relationships with Medicare patients (mostly 65+)
• Check in regularly (calls, virtual, or in-person)
• Support mental, social, and emotional needs
Care Coordination (High-Touch)
• Work closely with doctors, nurses, and care teams
• Schedule appointments, follow-ups, and screenings
• Track patient progress and close care gaps
Medicare + Value-Based Care
• Help patients understand and use their Medicare benefits
• Support preventive care and chronic condition management
• Focus on outcomes (reduce ER visits, readmissions)
Social Work Support
• Identify social barriers (housing, food, transportation)
• Connect patients to community resources
• Advocate for patient needs
Transitions of Care
• Support hospital discharge → home
• Set up home care, rehab, or services
• Ensure smooth, safe transitions
Documentation & Compliance
• Document all interactions clearly
• Follow care plans and compliance standards
• Use care management systems (EMR/CRM)
Qualifications
Education
• BSW or MSW (Social Work)
Experience
• Medicare population (especially high-risk / chronic conditions)
• Care coordination, case management, or community health
• Hospital, home care, or health plan experience
Skills
• Strong communication (simple, clear, patient-friendly)
• Empathy + relationship-building
• Organized and able to manage multiple patients
• Knowledge of Medicare + community resources
Nice to Have
• LMSW / LCSW
• Experience in value-based care models
• Medicare Advantage experience
• Bilingual (Spanish preferred)
Pay: $17.00 - $20.00 per hour
Work Location: Remote
Apply tot his job
Apply To this Job