Integrated Care Social Worker

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 that will require in clinic presence in Orange County and Osceola Counties, 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.   Scope   includes but   not   limited to the following:   Socioeconomic and   Psychosocial Assessment & Risk Identification   Conduct comprehensive psy chosocial   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 Co ach   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 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   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 Florida requirements .   (LCSW welcome but not required)   Bilingual in English and Spanish with the ability to read/write/speak in both languages fluently. 3+ years of experience in   clinical   social work   support ing   patients , and their case coordination,   across   complex care clinical   and   community ‑ based services   ecosystem s   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 improve 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, 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 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   Additional Information To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:   At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.   Scheduled Weekly Hours 40 Pay 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 year This 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 h