Population Health Social Worker

About the role

The Population Health Social Worker at Clever Care Health Plan is responsible for providing comprehensive psychosocial assessment, care coordination, advocacy, and resource navigation for Medicare Advantage members with complex medical, behavioral, functional, and social needs. This role requires a Master's Degree in Social Work and at least three years of relevant experience.

Responsibilities

• Conduct comprehensive psychosocial assessments to identify barriers affecting members' health, safety, independence, and overall well-being.
• Assess social determinants of health including housing instability, food insecurity, transportation, financial hardship, caregiver support, social isolation, language barriers, and access to healthcare services.
• Develop individualized care plans that address psychosocial, behavioral, environmental, and community resource needs in collaboration with members, caregivers, and interdisciplinary teams.
• Provide social work consultation for members enrolled in Transitions of Care, Complex Case Management, SNP Case Management, and other Population Health programs.
• Collaborate with Registered Nurses, Care Coordinators, Medical Directors, Primary Care Providers, Behavioral Health providers, Utilization Management, Pharmacy, and community organizations to support comprehensive care planning.
• Facilitate referrals to community-based organizations, government assistance programs, behavioral health services, transportation programs, caregiver resources, home and community-based services, and other available support programs.
• Assist members in accessing Medicare, Medicaid, Social Security, disability benefits, long-term services and supports (LTSS), and other applicable community resources.
• Provide crisis intervention, supportive counseling, motivational interviewing, and problem-solving strategies to assist members experiencing psychosocial challenges.
• Support safe discharge planning and transitions of care by addressing non-clinical barriers that may impact successful recovery and continuity of care.
• Educate members and caregivers regarding available benefits, community resources, advance care planning, caregiver support services, and self-advocacy.
• Participate in interdisciplinary care team (ICT) meetings and contribute psychosocial recommendations that support person-centered care planning.
• Advocate for members to ensure equitable access to medically necessary services and community resources.
• Maintain accurate, timely, and complete documentation within the care management platform.
• Maintain current knowledge of federal, state, county, and community resources available to Medicare beneficiaries.
• Support quality improvement initiatives, health equity strategies, and organizational performance improvement activities.
• Maintain compliance with CMS Medicare Advantage regulations, NCQA accreditation standards, HIPAA, and applicable federal and state regulations.
• Participate in regulatory audits and documentation reviews as requested.
• Promote culturally responsive, trauma-informed, and member-centered care.
• Perform other duties as assigned.

Qualifications

• Licensures and Certifications: Master's Degree in Social Work (MSW) from an accredited school of social work required. LCSW preferred.
• Experience: Minimum of three (3) years of social work experience in healthcare, managed care, care management, hospital case management, behavioral health, community health, or related setting. Experience working with Medicare, Medicare Advantage, Medicaid, or managed care populations preferred. Experience coordinating community resources and addressing social determinants of health required. Experience supporting medically complex and vulnerable populations preferred. Population Health or Care Management experience preferred.
• Skills: Knowledge of psychosocial assessment methodologies, crisis intervention, motivational interviewing, and strengths-based care planning. Strong knowledge of Medicare Advantage, CMS regulations, NCQA accreditation standards, and Population Health principles. Knowledge of social determinants of health, health equity, and community resource navigation. Knowledge of behavioral health resources, long-term services and supports (LTSS), caregiver support programs, and public assistance programs. Excellent assessment, critical thinking, and problem-solving skills. Ability to establish trusting relationships with members, caregivers, providers, and interdisciplinary teams. Excellent verbal, written, and interpersonal communication skills. Strong organizational and time management skills with the ability to manage multiple priorities. Ability to work independently while collaborating effectively within an interdisciplinary care team. Proficiency with electronic health records, care management software, Microsoft Office Suite, and virtual communication platforms. Ability to maintain confidentiality and comply with HIPAA and organizational privacy requirements. Demonstrated commitment to cultural humility, member advocacy, health equity, and continuous quality improvement. Bilingual in Mandarin/Cantonese, Vietnamese, Korean, or Spanish preferred.

Benefits

Clever Care Health Plan offers a competitive salary range of $73,000 to $85,000 per year, along with comprehensive benefits including health insurance, retirement plans, paid time off, and professional development opportunities.

Pay

$73,000 to $85,000 per year

Schedule

This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.