Integrated Care Social Worker

About the Role

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 workdays.

Role 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.

• 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 exceed routine case coordination and familiarity or subject matter expertise of the 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).

Responsibilities

• Serve as the program’s primary resource for complex socioeconomic barriers and psychosocial 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 ensure socioeconomic barriers and psychosocial needs are addressed.
• Follow organizational policies related to safety, documentation, and attendance.

Requirements

• Education: Master’s degree in Social Work (MSW) from an accredited program.
• Licensure: Licensed or license-eligible per state requirements (LCSW welcome but not required).
• Language: Bilingual in English and Spanish with the ability to read/write/speak fluently in both languages.
• Experience: Minimum 3 years of experience in clinical social work supporting patients and their case coordination across complex care clinical and community-based services ecosystems.
• Experience working with high-risk, medically complex, or socially vulnerable populations.
• Demonstrated 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 improved outcomes.

Preferred Qualifications

• Experience addressing health-related social needs (HRSNs) and social determinants of health (SDOH), including housing instability, food insecurity, transportation barriers, financial strain, and 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

• 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.

Schedule

• Workstyle: Hybrid; requires regular onsite presence in the supported clinics.
• Location: Must reside near the designated market and clinics supported by the role to enable regular 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.
• Scheduled Weekly Hours: 40.

Additional Requirements

• This role is considered patient-facing and requires Tuberculosis (TB) screening.
• This role requires a valid state driver’s license and maintenance of 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, whichever is higher.

Pay

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, and certifications.

$65,000 - $88,600 per year. This job is eligible for a bonus incentive plan based on company and/or individual performance.

Benefits

Humana offers competitive benefits that support whole-person well-being, including:

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance.

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.

About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put patients at the center of everything we do. 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.