Integrated Care Social Worker

Social Worker in High-Risk Patient Management Program

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 will require in-clinic presence in Orange County and Osceola Counties, 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

Required Qualifications

• Master's degree in Social Work (MSW) from an accredited program.
• Licensure: Licensed or license-eligible per Florida requirements. (LCSW welcome but not required)
• Bilingual in English and Spanish with the ability to read/write/speak in both languages fluently.
• 3+ years of experience in clinical social work supporting patients, and their case coordination, across complex care clinical and community-based services ecosystems
• 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

Preferred Qualifications

• 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

Skills / Abilities / Competencies

• 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

Workstyle

• Workstyle: Hybrid; this role requires regular onsite presence in the clinics supported by the position.
• Location: Must reside near the designated market and clinics supported by the role to enable regular in-clinic collaboration and patient support.
• Clinic Presence: Expected to work onsite in supported clinics 2–3 days per week, with remaining workdays completed from home based on business and patient needs.
• Hours: Monday–Friday; flexibility may be required to meet patient needs

Additional Information

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.

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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient's well-being.

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-