Care Management Social Worker

Conviva Care Solutions; The Villages (FL); Hybride; USD 55 000 - 75 000; Plein temps

Résumé du poste

Conviva Care Solutions seeks a Social Worker to provide psychosocial assessment, care coordination, and interventions for our highest-risk patient population. The role focuses on addressing social, environmental, and behavioral barriers that affect engagement and transitions across settings, delivering time-limited, goal-oriented support.

Hybrid role; location near assigned markets and clinics with onsite 2-3 days per week and remote days otherwise.

Qualifications

• Master's degree in Social Work (MSW) from an accredited program.
• Licensed or license-eligible per state requirements (LCSW welcome but not required).
• Minimum 3 years of experience in clinical social work supporting patients across complex care and community-based services.
• Experience working with high-risk, medically complex or socially vulnerable populations.
• Experience addressing health-related social needs and social determinants of health impacting patient outcomes and system navigation.

Responsabilités

• Serve as the primary resource for complex socioeconomic barriers and psychosocial needs.
• Identify patients with 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 Manager and PCP to address socioeconomic barriers and psychosocial needs.
• Follow organizational policies related to safety, documentation, and attendance.

Connaissances

Clinical social work

Care coordination

Behavioral health screening

Resource navigation

Stakeholder collaboration

Formation

MSW degree

Description du poste

Become a part of our caring community

The Social Worker 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. 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

Social Workers 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 Team 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 Team

• 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 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 Manager 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 state requirements. (LCSW welcome but not required)
• 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 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 medi