Social Services Coordinator – Telehealth

Position Summary

The Social Services Coordinator supports patients during the critical weeks after a hospital or facility discharge. Transitional Care Management services will be provided via telehealth by identifying and addressing the social and logistical barriers that affect their health. Working virtually with patients, families, providers, and community organizations, the coordinator connects patients to resources and ensures smooth transitions across care settings. This role helps make virtual care accessible, equitable, and effective.

Key Responsibilities

Resource Navigation, Referrals and Care Coordination

Connect patients with community resources
Maintain an up-to-date directory of local and regional resources
Follow up on referrals to confirm services were received and needs were met
Track patient engagement and follow escalation protocols
Assist with arranging post-acute services

Documentation and Compliance

Maintain patient confidentiality in accordance with HIPAA and organizational policy
Adhere to state telehealth regulations, mandatory reporting requirements, and professional ethics standards
Contribute data for quality improvement, program reporting, and grant or contract requirements

Outreach and Education

Educate patients and families on community services, and self-management resources
Build and maintain relationships with community partners and referral agencies
Participate in outreach or program development initiatives as assigned

Qualifications

Required

2+ years of experience in social services, case management, or care coordination, preferably in a healthcare setting
Knowledge of community resources, public benefit programs, and social determinants of health
Excellent written and verbal communication skills
Proficiency with EHR systems, video conferencing platforms, and standard office software
Ability to work independently and manage a caseload in a remote environment

Preferred

Licensed Clinical Social Worker (LCSW), or state-equivalent licensure
Experience delivering services via telehealth
Bilingual or multilingual abilities
Experience serving Medicaid, Medicare, or other underserved populations
Familiarity with Transitional Care Management and CMS requirements
Experience in transitions of care, hospital discharge planning, or readmission reduction

Working Conditions and Technology

Remote; requires a private, HIPAA-compliant workspace with reliable high-speed internet
Extended time at a computer and on video or phone calls
Flexible scheduling may be needed to accommodate patient availability
Organization-provided laptop and secure software access

Disclaimer

This job description describes the general nature and level of work performed in this position. It is not intended to be an exhaustive list of duties, responsibilities, qualifications, or requirements. Responsibilities may be modified based on organizational needs, patient population, regulatory requirements, and program.

Pay: $30.00 - $33.00 per hour

Expected hours: 40.0 per week

Benefits:

401(k)
Dental insurance
Health insurance
Paid time off
Vision insurance

Location:

California (Required)

Work Location: Remote

ONclick Health

New Jobs

Social Services Coordinator - Telehealth