Website Tri-County Family Medicine

Caring for Our Communities

Social Work Care Managers at TCFM serve the most vulnerable people in our community! 

While working with the underserved can present challenges, the rewards are tenfold. The ideal candidate will possess previous case management experience and have a passion for serving the community. As a Social Work Care Manager, you will work to manage a population of patients with complex medical needs. You will help address any medical, social, economic needs that might negatively impact the health of the patient, provide linkage to appropriate community resources and make referrals to appropriate services to help improve care outcomes.


  • Perform psychosocial assessments of patients and families referred by care managers and providers
  • Making visits to patients’ homes or out in the community for the purpose of patient engagement
  • Accessing various HIT resources to gain additional information to use in psychosocial assessment
  • Develop and implement care plans in collaboration with patients, addressing the Social Determinants of Health. 
  • Coordinate referrals to and act as a liaison to community agencies
  • Participate in patient care team meetings
  • Handle confidential information in accordance with HIPAA as well as state and federal privacy and confidentiality requirements


  • Graduate of an approved program allowing licensure to practice in NYS as a BSW or MSW.  
  • Must maintain a current and valid registration certificate
  • 3-5 years of clinical social work experience, preferably with 3-5 years of community health experience with an adult population
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