Justice Transition and Street Medicine Social Worker Care Manager

WACO FAMILY MEDICINE•Waco, TX

29d

About The Position

The Social Worker manages a caseload of individuals transitioning from incarceration into community-based care and collaborates with the Street Medicine Mobile Team. The role combines re-entry coordination with street-based medical and behavioral health outreach to support individuals who are recently released, unhoused, or disconnected from care. Responsibilities include assessments, warm handoffs, and care coordination to promote stabilization, healthcare engagement, and reduced recidivism.

Requirements

Master’s degree in social work (LMSW or LCSW-Texas). The social worker can be on the non-clinical or clinical track.
Valid Texas driver’s license, liability insurance, and reliable transportation.
Proficiency with technology and electronic systems, including Microsoft Teams, Outlook, Epic, Excel, and related tools.
Ability to build trust with individuals experiencing trauma, instability, or homelessness.
Strong communication, organization, and documentation skills.
Comfortable working in dynamic, unpredictable community settings.

Nice To Haves

Bilingual in English/Spanish

Responsibilities

Coordinate warm handoffs from incarceration into Waco Family Medicine services.
Conduct psychosocial assessments and identify immediate post‑release needs (medication continuity, housing, transportation, behavioral health support, recovery programs, social needs, safety planning).
Assist with ID recovery, benefits reinstatement, insurance enrollment, medical records, and resource linkage.
Partner with McLennan County Jail staff on pre-release planning.
Schedule appointments and coordinate transportation.
Engage unhoused or recently released individuals through mobile outreach.
Provide motivational interviewing and harm-reduction education.
Assist with disease management follow-up, medication access, and behavioral health services to improve health outcomes.
Build trauma‑informed, person‑centered relationships.
Support transportation coordination, appointment reminders, and warm handoffs to clinical care.
Develop individualized care plans for medical, behavioral health, re-entry, and social needs.
Coordinate referrals for healthcare, substance use treatment, housing, food support, employment, and benefits.
Provide ongoing follow-up via phone, outreach, and clinic visits.
Monitor and adjust care plans as needs evolve.
Complete timely and accurate documentation in the EHR.
Maintain assessments, care plans, releases, and follow-up documentation.
Participate in meetings, case conferences, and quality improvement.
Work with the Director of Care Management to operationalize workflows and program goals.
Collaborate with a multidisciplinary team including medical, behavioral health, and outreach partners.
Assist in refining program processes and providing feedback for program development and evaluation.