Hybrid Social Worker – High-Risk Care Coordination

CenterWell Senior Primary Care; Orlando (FL); Hybrid; USD 65,000 - 89,000; Full time

Job summary

CenterWell Senior Primary Care in Florida is seeking a Social Worker for the High-Risk Patient Management program to assess psychosocial needs, coordinate care, and connect patients with community resources. This hybrid role requires in-clinic presence 2–3 days per week in Orange County and Osceola Counties, with remote work on remaining days; bilingual English/Spanish and MSW licensure are preferred.

You will collaborate with Care Coaches and PCPs to address barriers, support transitions, and

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

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

Skills

Psychosocial assessment

Care navigation

Communication skills

Cultural humility

Independent work

Documentation

Education

Master’s degree in Social Work (MSW)

Licensure per Florida requirements (LCSW welcome)

Job description

CenterWell Senior Primary Care in Florida is seeking a Social Worker for the High-Risk Patient Management program to assess psychosocial needs, coordinate care, and connect patients with community resources. This hybrid role requires in-clinic presence 2–3 days per week in Orange County and Osceola Counties, with remote work on remaining days; bilingual English/Spanish and MSW licensure are preferred.

You will collaborate with Care Coaches and PCPs to address barriers, support transitions, and