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 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 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 

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 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 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