Integrated Care Social Worker

Job Overview 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. 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 Workstyle & Logistics Mobile presence: involves 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 area 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 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. Pay & Benefits Scheduled Weekly Hours: 40 Pay Range: $65,000 – $88,600 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance. Description of Benefits: Humana, Inc. and its affiliated subsidiaries offer competitive benefits that support whole‑person well‑being. Benefits include medical, dental, and vision coverage; a 401(k) retirement savings plan; paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave; short‑term and long‑term disability; life insurance; and 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 also follows affirmative action in compliance with Section 503 of the Rehabilitation Act and VEVRAA. #J-18808-Ljbffr CenterWell Senior Primary Care