Job Details: Job Location: Madison Cooper Clinic - Waco, TX, Position Type: Full Time, Education Level: 4 Year Degree, Salary Range: Undisclosed, Job Shift: Day, Job Category: Health Care, REPORTS TO: Director of Care Management and Director of Integrated Behavioral Health   EDUCATION & EXPERIENCE LMSW Preferred: Experience in social services, counseling, case management, or vocational rehabilitation Experience providing social services in healthcare settings   SKILLS Ability to learn and apply case management, disease management, and patient education skills. Strong interpersonal skills with the ability to build effective relationships across medical teams and with patients. Proficiency in problem identification and care plan development. Professional interaction skills with medical providers and other healthcare professionals. Ability to learn and apply knowledge of chronic physical and behavioral health conditions. Skillfully conduct health assessments and screenings. Ability to learn and apply evidence-based behavioral strategies, including motivational interviewing. Strong written and oral communication skills.   PRIMARY DUTIES Coordinate and manage care for high-risk patients to improve outcomes and minimize unnecessary hospital utilization. Develop and maintain a tracking system for seamless care coordination across medical services, including transitions and referrals. Identify and address gaps in patient care through proactive outreach and follow-up services. Implement standing delegated orders and management protocols. Participate in or lead regular Care Team meetings. Serve as a liaison between primary care, specialty, and behavioral health services for coordinated patient treatment plans. Offer coaching to patients on self-management for chronic conditions. Conduct comprehensive psychosocial needs assessments. Develop individualized care plans focusing on disease prevention and self-care improvement. Assist patients in navigating the healthcare system by coordinating with specialty care Apply knowledge of community resources to address care gaps or improve quality of life conditions. Provide appropriate supervised clinical care to meet Licensed Clinical Social Worker certification requirements.   OTHER DUTIES As assigned by supervisor.   Qualifications: PHYSICAL AND MENTAL REQUIREMENTS Possess a valid Texas driver’s license and appropriate liability insurance Access to personal transportation Visual and auditory accuracy Shift length varies Indoor setting Continuous use of computer Long periods of sitting Frequent use of telephone and/or smart devices Continuous repetitive grasping and manipulation of both hands Continuous conversational communication Occasional reaching, walking, squatting, bending, kneeling, twisting and climbing Occasionally carrying, lifting, pushing and pulling of up to 25 lbs. Occasionally working in confined, noisy, dusty areas Understand/carry out simple/detailed, oral/written instructions Memorize and retain instructions Read and interpret detailed specifications Mental competency Tobacco non-user Physical accommodations will be implemented where necessary and feasible