Care Manager Social Worker
Monogram HealthGulfport, Mississippi, United States
Posted February 2, 2026
Full Time
About the Company
Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions.
Job Description
Monogram Health is looking for skilled Social Workers to make a difference in patients' lives by removing economic and behavioral barriers to health outcomes.
Requirements
- 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
Benefits
- Comprehensive Benefits
- Financial & Retirement Support
- Time Off & Leave
- Wellness & Growth
