Integrated Care Social Worker

CenterWell • Orange, FL

1d • Hybrid

About The Position

Become a part of our caring community The Social Worker in the High‑Risk Patient Management (HRPM) program provides psychosocial assessment, care coordination, and social needs intervention for the organization’s highest‑risk patient population, representing approximately the top 5% of patients with the greatest medical, functional, behavioral, and social complexity. As the program’s primary resource for complex psychosocial needs, this role identifies and addresses social, environmental, and behavioral barriers that interfere with care engagement and safe transitions across settings. Working in close partnership with the Care Coach (LPN), the Social Worker delivers time‑limited, goal‑oriented interventions and connects patients and caregivers to appropriate community social, and behavioral health resources. This hybrid role must be located near the assigned market and clinics supported, with an expectation to work onsite in the clinics 2–3 days per week and from home on remaining workdays Role Scope Social Workers in HRPM serve as specialist support for patients whose outcomes and utilization are driven by psychosocial complexity, including social instability, financial hardship, behavioral health concerns, caregiver strain, or difficulty navigating healthcare and social service systems. Scope includes but not limited to the following: Socioeconomic and Psychosocial Assessment & Risk Identification Conduct comprehensive psychosocial assessments addressing housing stability, food insecurity, transportation, financial stress, safety concerns, caregiver capacity, mental health or substance use factors, and health literacy (non diagnostic; screening only) Identify socioeconomic barriers and psychosocial drivers contributing to poor adherence, frequent emergency department use, or avoidable hospitalizations Social Needs Intervention & Resource Navigation Support access to high‑barrier services and resources, including long‑term care, housing supports, and community‑based services Assist with referrals, applications, documentation (per regulatory and compliance standards), and follow‑up Coordinate across agencies and providers to address gaps impacting care stability and engagement Behavioral Health Support 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 Hospital & Emergency Department Follow‑Up (Psychosocial Focus) Partner with the Care Coach following hospitalizations or emergency department visits to address psychosocial barriers to recovery and follow‑up Support stabilization and continuity of care to reduce avoidable readmissions or ED revisits Collaboration with Care Coach Receive referrals when socioeconomic barriers and psychosocial complexity exceeds routine case coordination and familiarity or subject matter expertise of care coach supporting community and referral resource engagement Provide assessment findings, recommendations, and follow‑through to support integrated care planning Participate in high risk rounds as appropriate (at minimum, for patients in own caseload) Duties and Responsibilities Serve as the program’s primary resource for complex socioeconomic barriers and psychosocial needs Prioritize patients identified as having high psychosocial or social risk Provide time ‑ limited, outcomes ‑ focused social work interventions Coordinate with internal and external partners to secure services Assist in mitigating crises that threaten care continuity or patient safety Partner with Care Coach and PCP to ensure socioeconomic barriers and psychosocial needs are addressed Follow organizational policies related to safety, documentation, and attendance Use your skills to make an impact

Requirements

• Master’s degree in Social Work (MSW) from an accredited program
• Licensed or license ‑ eligible per state requirements
• Bilingual in English and Spanish with the ability to read/write/speak fluently in both languages
• Minimum 3 years of experience in clinical social work support ing patients , and their case coordination, across complex care clinical and community ‑ based services ecosystem s
• Experience working with high ‑ risk, medically complex or socially vulnerable populations
• Demonstrated experience addressing health-related social needs and social determinants of health impacting patient outcomes, and system navigation to optimize patient resourcing and engagement in support of improve outcomes
• Strong psychosocial assessment and problem ‑ solving skills
• Effective navigation of healthcare and social service systems
• Excellent interpersonal, engagement, and communication skills
• Cultural humility and patient ‑ centered approach
• Ability to work independently within a lean clinical model
• Strong organizational and documentation skills
• Must reside near the designated market and clinics supported, to enable regular in-clinic collaboration and patient support.
• Valid state driver's license
• Maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

Nice To Haves

• LCSW welcome but not required
• Experience addressing health related social needs (HRSNs) and social determinants of health (SDOH), including housing instability, food insecurity, transportation barriers, financial strain, access to benefits
• Experience working with patients experiencing psychosocial complexity, such as 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

Responsibilities

• Conduct comprehensive psychosocial assessments addressing housing stability, food insecurity, transportation, financial stress, safety concerns, caregiver capacity, mental health or substance use factors, and health literacy (non diagnostic; screening only)
• Identify socioeconomic barriers and psychosocial drivers contributing to poor adherence, frequent emergency department use, or avoidable hospitalizations
• Support access to high‑barrier services and resources, including long‑term care, housing supports, and community‑based services
• Assist with referrals, applications, documentation (per regulatory and compliance standards), and follow‑up
• Coordinate across agencies and providers to address gaps impacting 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 Coach following hospitalizations or emergency department visits to address psychosocial barriers to recovery and follow‑up
• Support stabilization and continuity of care to reduce avoidable readmissions or ED revisits
• Receive referrals when socioeconomic barriers and psychosocial complexity exceeds routine case coordination and familiarity or subject matter expertise of care coach supporting community and referral resource engagement
• Provide assessment findings, recommendations, and follow‑through to support integrated care planning
• Participate in high risk rounds as appropriate (at minimum, for patients in own caseload)
• Serve as the program’s primary resource for complex socioeconomic barriers and psychosocial needs
• Prioritize patients identified as having high psychosocial or social risk
• Provide time ‑ limited, outcomes ‑ focused social work interventions
• Coordinate with internal and external partners to secure services
• Assist in mitigating crises that threaten care continuity or patient safety
• Partner with Care Coach and PCP to ensure socioeconomic barriers and psychosocial needs are addressed
• Follow organizational policies related to safety, documentation, and attendance

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level