Medical Social Worker

Cinqcare • Baltimore, MD

4d • Hybrid

About The Position

CINQCARE is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care. The Medical Social Worker provides direct and consultative support to address complex Social Determinants of Health (SDOH) needs for Grace at Home family members. This role partners with interdisciplinary care teams to assess social risk, develop intervention plans, and connect family members to appropriate healthcare payor and community-based resources. The Medical Social Worker builds and maintains a comprehensive resource database to support scalable, high-quality social care interventions. This position plays a critical role in improving access, care coordination, and outcomes for individuals with complex social needs.

Requirements

• Master’s degree in Social Work (MSW) from an accredited program required.
• 3+ years of experience providing social work services in healthcare, care management, or community-based settings.
• Experience addressing complex social determinants of health for medically and socially complex populations.
• Strong assessment, care coordination, and advocacy skills.
• Knowledge of healthcare payer benefits, community-based resources, and social service systems.
• Excellent communication and documentation skills.
• Ability to work independently and collaboratively in remote and field-based environments.
• Proficiency with electronic health records (EHRs) and care management platforms.
• Ability to conduct community-based services assessments, including evaluation of local resource availability, service capacity, eligibility criteria, and gaps impacting family member access to care.

Nice To Haves

• Experience working with interdisciplinary care teams preferred.
• Bilingual candidates strongly preferred.

Responsibilities

• Provide direct social work services to family members with complex SDOH needs identified through interdisciplinary care teams.
• Conduct psychosocial assessments to identify barriers related to housing, food insecurity, transportation, financial strain, caregiver support, behavioral health access, and other social drivers of health.
• Develop individualized care and resource plans in collaboration with family members, caregivers, and clinical teams.
• Provide ongoing follow-up, advocacy, and care coordination to support successful resolution of identified social needs.
• Serve as a subject matter expert for SDOH, providing consultation and guidance to interdisciplinary care teams.
• Participate in case conferences and care planning discussions to support holistic, patient-centered care.
• Recommend appropriate social care interventions aligned with clinical and care management goals.
• Build, maintain, and continuously update a comprehensive database of healthcare payer benefits, community-based organizations, and social service resources.
• Establish relationships with community partners, social service agencies, and payer representatives to enhance referral pathways.
• Ensure resource information is accurate, accessible, and aligned with eligibility and referral requirements.
• Document all assessments, interventions, referrals, and outcomes in designated systems in accordance with organizational, regulatory, and payer requirements.
• Track and report SDOH needs, interventions, and outcomes to support value-based care (VBC) contracts, quality initiatives, and payer reporting requirements.
• Support SDOH-related reporting for value-based programs, including ACOs, MSSP, HEDIS, and other payer-specific initiatives, as applicable.
• Ensure accurate capture of social risk factors, interventions, and resolutions to support quality measurement, risk stratification, and total cost of care analyses.
• Collaborate with analytics, quality, and clinical teams to validate SDOH data and improve reporting accuracy and completeness.
• Identify systemic gaps in available social resources and escalate trends to leadership.
• Contribute to the development of workflows, tools, and best practices for SDOH support across the organization.
• Stay current on emerging SDOH models, community resources, and regulatory requirements.
• Perform other job-related duties as assigned.

Benefits

• Medical Plans: Two comprehensive options offered to Team members.
• 401K: 4% employer match for your future.
• Dental & Vision: Flexible plans with in-network savings.
• Paid Time Off: Generous PTO, holidays, and wellness time.
• Extras: Pet insurance, commuter benefits, mileage reimbursement, CME for providers, and company-provided phones for field staff.

What This Job Offers

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