Integrated Care Social Worker

Become a part of our caring community The Integrated Care Social Worker supports the organization's highest risk patient population, representing approximately the top 5% of patients with the greatest medical, functional, behavioral, and social complexity. By working closely with integrated care team members, you will serve as the primary source for complex psychosocial needs, identifying and addressing social, environmental, and behavioral barriers that interfere with care engagement and safe transitions across settings. The Integrated Social Worker provides specialized support for patients whose outcomes and utilization are impacted by psychosocial complexity, such as social instability, financial hardship, behavioral health concerns, caregiver strain, or difficulty navigating healthcare and social services. You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas. You will report to a Care Integration Team Manager. Key Responsibilities Assessment and Risk Identification: Conduct comprehensive psychosocial assessments to identify barriers such as housing, food insecurity, transportation, financial stress, safety concerns, caregiver capacity, mental health, substance use, and health literacy. Social Needs Intervention: Facilitate access to high-barrier services (e.g., long-term care, housing, community resources), assist with referrals and applications, and coordinate across agencies to close gaps in care. Behavioral Health Support: Provide short-term, supportive interventions, screen for behavioral health or substance use concerns, and connect patients to appropriate services. Care Transitions: Partner with Care Coaches following hospitalizations or ED visits to address psychosocial barriers and reduce avoidable readmissions. Collaboration: Work with Care Coaches and PCPs to integrate care plans, participate in high-risk rounds, and serve as the program's primary resource for complex psychosocial needs. Required Qualifications Active and unrestricted Licensed Master Social Worker (LMSW) in the state of Texas Bilingual in English and Spanish (with the ability to read, write and speak in both languages) 2+ years of clinical social work experience, including care coordination across complex clinical and community settings Experience working with high-risk, medically complex, or socially vulnerable populations Knowledge of health-related social needs (HRSNs) and social determinants of health (SDOH) Preferred Qualifications Experience addressing HRSNs and SDOH (e.g., housing, food insecurity, transportation, financial strain) Background in behavioral health support and working with psychosocial complexity Experience with seniors, medically complex patients, or population health/value-based care models This role has a mobile presence, involving travel to patients’ homes, healthcare facilities, community-based settings, and assigned clinics. Workstyle: Combination of clinic-based and field work Location: Must reside in Corpus Christi, TX or El Paso, TX metro Hours: Monday–Friday, 8:00 AM–5:00 PM; overtime may be required Additional Information TB Statement: This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. Driving Statement: This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to 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. Use your skills to make an impact Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $65,000 - $88,600 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options #J-18808-Ljbffr