Integrated Care Social Worker
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Overview
Job Description
Become a part of our caring community
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 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 workdaysRole 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 complexsocioeconomic barriers andpsychosocial 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 ensuresocioeconomic barriers andpsychosocial needs are addressed
Follow organizational policies related to safety, documentation, and attendance
Use your skills to make an impact
Required Qualifications
Master’s degree in Social Work(MSW) from an accredited program.
Licensure:Licensed or license‑eligible per state requirements.(LCSW welcome but not required)
Bilingual in English and Spanish with the ability to read/write/speak fluently in both languages
Experience:Minimum3years of experience inclinicalsocial worksupportingpatients, and their case coordination,acrosscomplex care clinicalandcommunity‑based servicesecosystems
Experience working with high‑risk, medically complex or socially vulnerable populations
Demonstrated experience addressinghealth-related social needs andsocial determinants of healthimpacting patient outcomes,and system navigationto optimize patientresourcing and engagementin support of improve outcomes
Preferred Qualifications
Experience addressinghealth related social needs (HRSNs) andsocial 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 roleto enableregular 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
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
40Pay 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 yearThis 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-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.
Automate your job search with Sonara.
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