Care Management Social Worker
About The Position
The Social Worker provides psychosocial assessment, care coordination, and social needs intervention for the organization’s highest-risk patients—approximately the top 5% with the greatest medical, functional, behavioral, and social complexity. As the primary resource for complex psychosocial needs, the role identifies and addresses social, environmental, and behavioral barriers to care engagement and safe transitions across settings. The Social Worker delivers time-limited, goal-oriented interventions and connects patients and caregivers with appropriate community, social, and behavioral health resources. This hybrid, patient-facing role must be located near the assigned market and supported clinics. It requires onsite work in clinics 2–3 days per week, with the remaining workdays from home. The role serves patients whose outcomes and utilization are affected by issues such as social instability, financial hardship, behavioral health concerns, caregiver strain, or difficulty navigating healthcare and social-service systems. The position is part of Humana’s tuberculosis screening program, and selected candidates must undergo TB screening.
Requirements
- Master’s degree in Social Work (MSW) from an accredited program.
- Licensed or license-eligible according to state requirements; LCSW is welcome but not required.
- At least 3 years of clinical social work experience supporting patients and their case coordination across complex-care clinical and community-based service systems.
- Experience working with high-risk, medically complex, or socially vulnerable populations.
- Demonstrated experience addressing health-related social needs and social determinants of health that affect patient outcomes, and navigating systems to optimize patient resources and engagement.
- Strong psychosocial assessment and problem-solving skills.
- Effective navigation of healthcare and social-service systems.
- Excellent interpersonal, engagement, and communication skills.
- Cultural humility and a patient-centered approach.
- Ability to work independently within a lean clinical model.
- Strong organizational and documentation skills.
Nice To Haves
- Experience addressing health-related social needs and social determinants of health, including housing instability, food insecurity, transportation barriers, financial strain, and access to benefits.
- Experience working with patients experiencing psychosocial complexity, including caregiver stress, social isolation, elder abuse, chronic stress, grief, trauma related to illness, or difficulty coping with functional decline.
- Experience working with seniors or medically complex patients.
- Experience in population health or value-based care models.
- Familiarity with resources and care coordination.
- LCSW licensure.
Responsibilities
- Conduct comprehensive psychosocial assessments, including housing stability, food insecurity, transportation, financial stress, safety, caregiver capacity, mental health or substance-use factors, and health literacy screening.
- Identify socioeconomic barriers and psychosocial factors contributing to poor adherence, frequent emergency department use, or avoidable hospitalizations.
- Help patients access high-barrier services and resources, including long-term care, housing supports, and community-based services.
- Assist with referrals, applications, documentation, and follow-up in accordance with regulatory and compliance standards.
- Coordinate with agencies and providers to address gaps affecting care stability and engagement.
- Provide short-term, supportive, non-therapeutic interventions for patients coping with illness-related distress, functional decline, or social instability.
- Screen for behavioral health or substance-use concerns and facilitate referrals as indicated; support engagement with recommended behavioral health services.
- Partner with the Care Team after hospitalizations or emergency department visits to address psychosocial barriers to recovery and follow-up and support continuity of care.
- Serve as the primary resource for complex socioeconomic barriers and psychosocial needs, prioritizing patients with high psychosocial or social risk.
- Provide time-limited, outcomes-focused social work interventions and coordinate with internal and external partners to secure services.
- Assist in mitigating crises that threaten care continuity or patient safety.
- Partner with the Care Manager and PCP to ensure socioeconomic barriers and psychosocial needs are addressed.
- Provide assessment findings, recommendations, and follow-through to support integrated care planning.
- Participate in high-risk rounds as appropriate, at minimum for patients in the Social Worker’s caseload.
- Follow organizational policies related to safety, documentation, and attendance.
Benefits
- Medical, dental, and vision benefits.
- 401(k) retirement savings plan.
- Paid time off.
- Company and personal holidays.
- Paid parental and caregiver leave.
- Short-term and long-term disability.
- Life insurance.
- Bonus incentive plan based on company and/or individual performance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
