Care Management Social Worker

Social WorkerThe Social Worker 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. 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 must be located near the assigned market and clinics supported, with an expectation to work onsite in the clinics 2–3 days per week and from home on remaining workdays.Social Workers 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 IdentificationConduct 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 hospitalizationsSocial Needs Intervention & Resource NavigationSupport access to high-barrier services and resources, including long-term care, housing supports, and community-based servicesAssist with referrals, applications, documentation (per regulatory and compliance standards), and follow-upCoordinate across agencies and providers to address gaps impacting care stability and engagementBehavioral Health SupportProvide short-term, supportive, non-therapeutic interventions for patients coping with illness-related distress, functional decline, or social instabilityScreen for behavioral health or substance use concerns and facilitate referrals as indicatedSupport patient engagement and activation with behavioral health services when recommendedHospital & Emergency Department Follow-Up (Psychosocial Focus)Partner with the Care Team following hospitalizations or emergency department visits to address psychosocial barriers to recovery and follow-upSupport stabilization and continuity of care to reduce avoidable readmissions or ED revisitsCollaboration with Care TeamReceive 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 engagementProvide assessment findings, recommendations, and follow-through to support integrated care planningParticipate in high-risk rounds as appropriate (at minimum, for patients in own caseload)Duties and ResponsibilitiesServe as the primary resource for complex socioeconomic barriers and psychosocial needsPrioritize patients identified as having high psychosocial or social riskProvide time-limited, outcomes-focused social work interventionsCoordinate with internal and external partners to secure servicesAssist in mitigating crises that threaten care continuity or patient safetyPartner with Care Manager and PCP to ensure socioeconomic barriers and psychosocial needs are addressedFollow organizational policies related to safety, documentation, and attendanceRequired QualificationsMaster's degree in Social Work (MSW) from an accredited program.Licensure: Licensed or license-eligible per state requirements. (LCSW welcome but not required)Experience: Minimum 3 years of experience in clinical social work supporting patients, and their case coordination, across complex care clinical and community-based services ecosystemsExperience working with high-risk, medically complex or socially vulnerable populationsDemonstrated 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 outcomesPreferred QualificationsExperience addressing health related social needs (HRSNs) and social determinants of health (SDOH), including housing instability, food insecurity, transportation barriers, financial strain, access to benefitsExperience 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 declineExperience working with seniors or medically complex patientsExperience in population health or value-based care modelsFamiliarity with resources and care coordinationSkills / Abilities / CompetenciesStrong psychosocial assessment and problem-solving skillsEffective navigation of healthcare and social service systemsExcellent interpersonal, engagement, and communication skillsCultural humility and patient-centered approachAbility to work independently within a lean clinical modelStrong organizational and documentation skillsWorkstyle: Hybrid; this role requires regular onsite presence in the clinics supported by the position.Scheduled Weekly Hours: 40Pay Range: $65,000 - $88,600 per yearDescription 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 UsAbout 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-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com.Equal Opportunity EmployerIt 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.