Catholic Health Initiatives Social Worker - Outpatient Care Coordinator in OMAHA, Nebraska

Social Worker - Outpatient Care Coordinator


Your time at work should be fulfilling. Rewarding. Inspiring. That’s what you’ll find when you join one of our non-profit CHI facilities across the nation. You’ll find challenging, rewarding work every day alongside people who have as much compassion as you. Join us and together we’ll create healthier, stronger communities. Imagine your career at Catholic Health Initiatives! at

Job Responsibilities

Works collaboratively with physicians, staff and other health care professionals within his/her clinically integrated network (CIN) to provide care coordination across the health care continuum for members within the CIN. Is an integral member of the health care team as well as the CIN department who works to ensure CIN members are able to navigate through the health care continuum while improving the coordination of care and member/family experience. Coordinates a wide range of community-based and healthcare support services for members. Works with physicians, staff and other resources (including external to the CIN) in various settings to address specific quality improvement/performance improvement initiatives. Collaborates with the CIN Population Health Care Management team on system-wide quality improvement/performance improvement initiatives.

Additional responsibilities for this health care role include:

  • Provides Coordination of Care across the care continuum including:

  • Assists in the identification of member populations needing care coordination

  • Assisting as a liaison with members and their families to physicians, clinical staff, community resources and others.

  • Promotes coordination with consulting physicians (specialists) and other health care providers, including referral management to other CIN physicians, transfer of clinically relevant information needed by the healthcare team.

  • Proactively acts as a member’s advocate, responding to and working to resolve concerns

  • Provides Health Promotion activities and education for members

  • Effective collaboration, communication and coordination among all responsible parties of an individual member’s multidisciplinary health care team striving to eliminate fragmentation, duplication or gaps in health care

  • Optimizes member and family independence through providing education and links to community resources

  • Works with families and members on needs that may or will affect the member’s health, including transportation issues, financial concerns, end of life planning, etc. in clinics, hospitals, care facilities and homes as necessary.

  • Identifies potential barriers related to patient’s home setting and self care/management needs and works with patient (and caregiver) to resolve issues.

  • Maintains an active case load of “at risk” members using CHI’s identification and stratification tools, direct referrals from the member’s healthcare team (physician, Professional Nurse Population Health Coach, hospital case manager, etc.) and other knowledge.

  • Accountability for results:

  • Understands and self-manages to support CIN-level success goals, including improvements in quality, cost of care and member experience for the CIN’s population.

  • Identifies opportunities for improvement (at individual, clinic and CIN levels) and actively works with healthcare and CIN team to correct or improve results.


  • Job RequirementsCurrent unrestricted license by the State of Nebraska as a social worker.

  • Masters of Social Work (MSW) required.

  • Five years of clinical, case management and/or healthcare experience is preferred.

  • Experience working with Medicare and Medicaid populations, and related social/economic issues preferred.

  • Experience in patient education preferred

  • Must have strong organizational (time management) skills, strong interpersonal skills and the ability to handle multiple priorities

  • Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.

  • Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)

  • Certification as Healthcare Coach or obtained within one year of hire.

  • Driver’s license-Auto insurance per Home Care policy

  • BLS or BLS instructor certification is required upon hire. Acceptable credentialing bodies and certifications include the following: American Red Cross: CPR/AED for the Professional Rescuer, American Safety and Health Institute: CPR, PRO, must say “Professional Level-with AED”, and American Heart Association: Basic Life Support for Healthcare Providers.

  • Ability to work autonomously within matrix environment without direct supervision or support.

  • Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire.

  • Completion and maintainence of all applicable Alegent-Creighton required learnings for the position

Join us at Catholic Health Initiatives, and become a part of our faith-based health system.

Job Professional Clinical/Allied Health


Daily Schedule Days-8a-5p

Scheduled Hours per 2-week Pay Period 80

Weekends Required Occasional

Req ID: 2018-R0162865

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.