Care Management Social Worker

CenterWell•The Villages, FL

4d•$65,000 - $88,600•Hybrid

About The Position

The Social Worker provides psychosocial assessment, care coordination, and social-needs intervention for the organization’s highest-risk patients—approximately the 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 that affect care engagement and safe transitions across settings. The Social Worker delivers time-limited, goal-oriented interventions and connects patients and caregivers with community, social, and behavioral health resources. This is a hybrid, patient-facing role located near the assigned market and supported clinics. The position requires onsite work in clinics 2–3 days per week, with the remaining workdays from home. The Social Worker specializes in 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 role screens for behavioral health and substance-use concerns but does not provide diagnosis or therapy. The position partners with care teams after hospitalizations and emergency department visits, contributes to integrated care planning and high-risk rounds, and supports continuity of care. The role is part of Humana’s tuberculosis screening program; selected candidates must undergo TB screening. The position is scheduled for 40 hours per week and is eligible for a performance-based bonus incentive.

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 experience in clinical social work supporting patients and their case coordination across complex-care clinical and community-based service ecosystems.
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.
Ability to work onsite in supported clinics 2–3 days per week and from home on remaining workdays.
Must undergo tuberculosis screening if selected for the patient-facing role.

Nice To Haves

Experience addressing health-related social needs (HRSNs) and social determinants of health (SDOH), including housing instability, food insecurity, transportation barriers, financial strain, and access to benefits.
Experience supporting patients with psychosocial complexity, such as caregiver stress, social isolation, elder abuse, chronic stress, grief, illness-related trauma, 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.

Responsibilities

Conduct comprehensive psychosocial assessments covering housing stability, food insecurity, transportation, financial stress, safety, caregiver capacity, mental health or substance-use factors, and health literacy through screening.
Identify socioeconomic barriers and psychosocial factors that contribute to poor adherence, frequent emergency department use, or avoidable hospitalizations.
Prioritize patients identified as having high psychosocial or social risk.
Support access to 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 patient engagement and activation with behavioral health services when recommended.
Partner with the Care Team after hospitalizations or emergency department visits to address psychosocial barriers to recovery and follow-up.
Support stabilization and continuity of care to help reduce avoidable readmissions and emergency department revisits.
Receive referrals when socioeconomic barriers or psychosocial complexity exceed routine case coordination or the care coach’s familiarity or subject-matter expertise.
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.
Serve as the primary resource for complex socioeconomic barriers and psychosocial needs.
Provide time-limited, outcomes-focused social work interventions and coordinate with internal and external partners to secure services.
Help mitigate crises that threaten care continuity or patient safety.
Partner with the Care Manager and PCP to ensure socioeconomic barriers and psychosocial needs are addressed.
Follow organizational policies related to safety, documentation, and attendance.