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Organizational Overview
Ponos Management Inc., specializes in providing compassionate value-based care through a physician-driven, home- and mobile-based model. Our comprehensive approach integrates social, mental, physical, and economic solutions, addressing the unique needs of patients with chronic conditions such as sickle cell disease, ulcerative colitis, Crohn's disease, and severe rheumatoid arthritis.
Our mission is to reduce emergency room visits and improve the quality of life for our patients through comprehensive, holistic coordinated care. We provide services currently on a national level.
Position Overview
The Licensed Clinical Social Worker (LCSW) Care Coordinator provides psychosocial support, care coordination, and advocacy for patients enrolled in the Ponos Care program.
The LCSW Care Coordinator plays a critical role in ensuring patients receive holistic care that integrates medical, behavioral, and social support services within the Ponos Care model, delivering patient centered care through a hybrid environment that includes telehealth services and in home patient visits within a 30-mile radius of Illinois.
This role works collaboratively with physicians, nurse practitioners, nurses, and other healthcare providers to address behavioral health needs and social determinants of health that impact patient outcomes.
Core Responsibilities
Care Coordination
- Lead care coordination activities and develop comprehensive care plans for patients.
- Ensure integration of medical, behavioral, and social services across the care continuum.
- Coordinate services among healthcare providers and community organizations.
Psychosocial Support
- Provide counseling and emotional support to patients and families.
- Assist patients in managing the psychological and social impacts of chronic illness.
- Advocate for patient needs within the healthcare system.
Community Resource Navigation
- Connect patients with community resources including housing, transportation, financial assistance, and support programs.
- Coordinate referrals to external agencies and support organizations.
Patient Monitoring
- Conduct regular follow-up with patients to monitor progress and adjust care plans.
- Maintain documentation including care plans, case notes, and progress reports within the EHR system.
Crisis Intervention
- Provide crisis intervention support when patients experience urgent behavioral health or social challenges.
- Coordinate emergency support services when necessary.
Quality Improvement
- Participate in initiatives focused on improving care delivery and patient outcomes.
- Support data collection and reporting related to care coordination activities.
Program Leadership & Strategy: Support the development and implementation of patient centered care coordination strategies. Assist leadership in strengthening behavioral health integration within the Ponos Care model. Identify opportunities to improve care delivery processes and patient support services. Contribute to interdisciplinary program planning and service delivery initiatives.
Regulatory & Compliance Oversight: Ensure compliance with federal and state healthcare regulations. Maintain adherence to Illinois social work licensing standards. Ensure patient confidentiality and compliance with HIPAA regulations. Participate in internal audits and quality reviews related to care coordination documentation.
Operational Excellence & Performance Management: Maintain accurate and timely documentation within electronic health record systems. Track patient progress and care coordination outcomes. Support operational improvements that enhance care delivery and patient experience. Ensure care coordination activities align with organizational goals and performance standards.
Team Leadership & Development: Collaborate with physicians, nurse practitioners, nurses, and clinical care teams. Serve as a behavioral health resource for interdisciplinary team members. Promote collaboration and communication across care teams. Support a culture of compassion, accountability, and patient centered care.
Innovation & Growth: Support innovative care coordination models that address social determinants of health. Contribute to program initiatives that improve patient access to community resources. Assist in developing strategies that enhance patient engagement and care outcomes. Participate in initiatives supporting the continued expansion of Ponos Care services.
QUALIFICATIONS AND EDUCATION
- Master’s Degree in Social Work from an accredited university.
- Licensed Clinical Social Worker with an unrestricted license in the State of Illinois.
- Minimum of three years of clinical social work experience, preferably in healthcare or chronic disease populations.
- Strong knowledge of care coordination and case management principles.
- Excellent communication and interpersonal skills.
- Ability to work independently and collaboratively within multidisciplinary healthcare teams.
- Proficiency with electronic health records and healthcare technology systems.
- Commitment to delivering high quality patient-centered care.
- Bilingual skills are a plus.
EEO STATEMENT
We are an Equal Opportunity Employer and are committed to fostering an inclusive and diverse workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, gender identity or expression), national origin, age, disability, genetic information, veteran status, or any other protected characteristic in accordance with applicable federal, state, and local laws. We believe inclusion strengthens our organization and enhances our ability to serve members and communities nationwide. We are committed to providing reasonable accommodation for qualified individuals with disabilities throughout the recruitment and employment process.
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