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 Apply tot his job Apply To this Job