Integrated Care Social Worker

Integrated Care Social Worker

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.

Scheduled Weekly Hours

40

Pay Range

$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.

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-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 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.