Licensed Social Worker – Care Coordination

Coordinate medical, behavioral health, and social service needs for assigned patients by completing psychosocial and Social Determinants of Health (SDOH) assessments and developing individualized care plans with SMART goals. Prioritize patients based on risk level and urgency while providing ongoing case management, advocacy, and referrals to community resources such as housing, food assistance, and transportation. Conduct transitions of care following hospitalizations, perform follow-up calls for discharged patients, and deliver crisis intervention and de-escalation in accordance with organizational protocols. Document all assessments, care plans, and encounters in the Athena Electronic Health Record while collaborating with physicians, nurses, and community partners on interdisciplinary case reviews. Maintain HIPAA compliance and attend required trainings and Core Curriculum sessions. Full-time role in Park Forest, IL, with ability to travel to other Aunt Martha's locations.