Social Worker

Description

Social Worker

Center for Primary Care
Who we are:

For over 30 years the Center for Primary Care (CPC) has cared for families in the CSRA by providing patients with the most convenient, accessible, and personal healthcare available. Our mission is to improve the health and wellbeing of the families we serve by providing compassionate and high-quality care in a joyful setting. The physicians, healthcare professionals, and support team at our 9 practices, plus laboratory, imaging, and corporate locations work to transform our mission into action.

What our employees say:

At Center for Primary Care, we understand that the work environment is as important as the hard work you do. Center for Primary Care is Great Place to Work Certified which means our employees share feedback on their work culture experiences and we listen and strive to create positive employee experiences centered on joy, trust, and belonging.

Learn more about CPC's culture and Great Place to Work Certification by clicking on the link below:


Working at Center for Primary Care | Great Place To Work®
Benefits for you and your family:

Coverage that cares for body, mind, and spirit.

Retirement plan with generous employer match and profit sharing.


Mental Health Support Services.

PTO and Paid Parental Leave.

Scheduled Bonuses.

Social Worker- Center for Primary Care

The Primary Care Social Worker supports patients and families in addressing social, behavioral, financial, and environmental factors that may affect health outcomes. As an integral member of the interdisciplinary primary care team, this position conducts psychosocial assessments, coordinates access to community resources, delivers brief supportive interventions, facilitates care transitions, and promotes safe, equitable, patient-centered care. The Social Worker collaborates with providers, nurses, care managers, medical assistants, behavioral health professionals, and community organizations to enhance access to services, patient engagement, and continuity of care.

This position is primarily based in an outpatient clinical environment and may include telephone, virtual, and community-based work. The role requires prolonged computer use, frequent communication with patients and team members, and the ability to manage competing priorities. Local travel may be required.
Key Responsibilities:

Essential Functions


Patient Assessment and Care Planning

• Conduct timely psychosocial assessments to identify patient strengths, needs, risks, preferences, and barriers to care.
• Create individualized social work care plans in collaboration with patients, caregivers, and the care team.
• Screen for social drivers of health, including food access, housing, transportation, utilities, safety, caregiver support, health literacy, and financial concerns.
• Determine when patients may benefit from behavioral health, community, care management, or specialty services.
• Assist with advance care planning and goals-of-care discussions in accordance with organizational policy and scope of practice.

Care Coordination and Resource Navigation

• Connect patients and families with appropriate community, financial, transportation, housing, food, caregiver, legal, and public-benefit resources.
• Assist patients with applications, referrals, and follow-up needed to access services.
• Coordinate with hospitals, post-acute providers, home health agencies, behavioral health services, pharmacies, and community organizations to support safe transitions and reduce gaps in care.
• Track referrals and close the loop with patients, caregivers, and the care team.
• Advocate for patient needs while supporting informed choice, dignity, independence, and self-management.

Brief Intervention and Safety Support

• Provide brief, evidence-informed supportive counseling, motivational interviewing, problem-solving, and education within scope of practice.
• Recognize and respond to concerns involving abuse, neglect, exploitation, interpersonal safety, self-harm, or other urgent psychosocial risks according to law, policy, and established escalation procedures.
• Collaborate with clinical team members to develop safety plans and arrange appropriate emergency or community-based support.
• Use trauma-informed, culturally responsive, and person-centered approaches in all interactions.

Team Collaboration, Documentation, and Quality

• Participate in huddles, case conferences, and interdisciplinary care-planning discussions.
• Advise and educate team members on psychosocial needs, community resources, and strategies to engage patients.
• Accurately and promptly document assessments, interventions, referrals, patient communications, and outcomes in the electronic health record.
• Protect patient confidentiality and comply with applicable privacy, ethical, regulatory, and organizational standards.
• Manage the assigned caseload, prioritize patients based on risk and need, and meet follow-up and documentation requirements.
• Support quality-improvement efforts and track outcomes related to referrals, resource connections, patient engagement, avoidable utilization, and care-plan progress.

Knowledge, Skills, and Abilities Required:

• Knowledge of psychosocial assessment, care coordination, crisis response, community resources, and social drivers of health.
• Ability to work effectively within an interdisciplinary, team-based primary care environment.
• Strong communication, organization, documentation, critical-thinking, and patient-advocacy skills.
• Ability to use electronic health records and standard workplace technology.
• Effective verbal and written communication skills.
• Completes assessments, documentation, and follow-up within established timeframes.
• Demonstrates timely closure of referrals and clear communication of outcomes to the care team.
• Maintains an organized caseload and prioritizes patients according to clinical and psychosocial risk.
• Supports measurable improvement in resource connection, patient engagement, care-plan progress, and continuity of care.
• Meets organizational standards for professionalism, compliance, teamwork, productivity, and patient experience.
• Demonstrates, through behavior, Center for Primary Care's Mission Statement.
• Takes responsibility for providing exceptional customer service.
• Always Maintains patient confidentiality; adheres to all HIPAA guidelines.
• Follows CPC guidelines, infection prevention practices, demonstrates appropriate use of PPE, performs hand washing according to policy, and follows safety and workplace incident procedures.
• Performs miscellaneous job-related duties as assigned.

Knowledge, Skills, and Abilities Preferred:

• Experience with Medicare, Medicaid, public benefits, community-based services, and value-based care.
• Experience supporting patients with complex medical, behavioral, functional, or socioeconomic needs.
• Bilingual or multilingual skills that reflect the needs of the patient population.

All essential functions must be performed. Reasonable accommodations may be made to enable individuals with qualified disabilities to perform the essential functionsThe above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified. Examples listed do not preclude the performance of other duties similar in nature or in level of complexity.

Requirements

Qualifications for Success:

Education, License/Certification, and Experience Requirements

Education Required: Master's Degree in Social Work from an accredited program.

Licensure, Certification or Registration Required: Current social work license or eligibility for licensure in the state of practice.

Experience: At least 1 + years of clinical nursing experience required. 2 + years of social work experience in primary care, ambulatory care, population health, behavioral health, chronic disease management, geriatrics, or complex care preferred. Independent clinical social work licensure, when appropriate to the position's responsibilities preferred. Experience with Athena One strongly preferred.

Additional Job Details:

Work Setting: On-site and in an outpatient clinical environment and may include telephone, virtual, and community-based work. Local travel may be required.


Job Type: Full-Time

Schedule: Monday-Friday

Compensation: Market competitive base pay, commensurate with education and experience.