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