Integrated Care Social Worker

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

Social Workers in HRPM serve as specialistsupportfor 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.

Scopeincludes butnotlimited to the following:

• Socioeconomic and Psychosocial Assessment & Risk Identification

• Conduct comprehensive psychosocialassessments 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)

• Identifysocioeconomic 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 activationwith behavioral health services when recommended

• Hospital & Emergency Department Follow‑Up (Psychosocial Focus)

• Partner with the Care Coachfollowing 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 whensocioeconomic barriers and psychosocial complexityexceedsroutinecase 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 inhigh risk roundsas appropriate(at minimum, for patients in own caseload)

• Serve as the program’s primary resource for complexsocioeconomic 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 ensuresocioeconomic barriers…