Population Health Social Worker

Paycom; Arcadia (CA); Hybrid; USD 73,000 - 85,000; Full time

Job summary

The Population Health Social Worker position at Clever Care Health Plan focuses on comprehensive psychosocial assessment, care coordination for Medicare Advantage members with complex needs, and connection to community resources. Collaboration with interdisciplinary teams ensures person-centered care planning and equity in access to services.

Responsibilities include transitions of care, SNP/CCIP programs, and addressing social determinants of health, while maintaining HIPAA compliance and

Qualifications

• Master's Degree in Social Work (MSW) from an accredited school of social work required.
• Minimum of three (3) years of social work experience in healthcare, managed care, care management, hospital case management, behavioral health, or related setting.
• Experience coordinating community resources and addressing social determinants of health required.
• Experience with Medicare/Medicaid populations preferred.

Responsibilities

• Conduct comprehensive psychosocial assessments to identify barriers affecting members' health, safety, independence, and well-being.
• Assess social determinants of health including housing instability, food insecurity, transportation, financial hardship, caregiver support, social isolation, language barriers, and access to healthcare services.
• Develop individualized care plans that address psychosocial, behavioral, environmental, and community resource needs in collaboration with members, caregivers, and interdisciplinary teams.
• Provide social work consultation for members enrolled in Transitions of Care, Complex Case Management, SNP Case Management, and other Population Health programs.
• Collaborate with Nurses, Care Coordinators, Medical Directors, Primary Care Providers, Behavioral Health providers, Utilization Management, Pharmacy, and community organizations to support care planning.
• Facilitate referrals to community-based organizations, government assistance programs, behavioral health services, transportation programs, caregiver resources, and LTSS.

Skills

Psychosocial assessment

Crisis intervention

Motivational interviewing

Care planning

Interdisciplinary collaboration

Education

MSW from an accredited school

LCSW preferred

Tools

Electronic Health Records

Care management software

Microsoft Office

Job description

Job Location: Arcadia Office - Arcadia, CA 91007
Position Type: Full Time
Salary Range: $73,000.00 - $85,000.00
This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

Why Join Us?

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Population Health Social Worker is responsible for providing comprehensive psychosocial assessment, care coordination, advocacy, and resource navigation for Medicare Advantage members with complex medical, behavioral, functional, and social needs. Working collaboratively with interdisciplinary teams, the Population Health Social Worker addresses psychosocial barriers that impact health outcomes, supports safe transitions of care, promotes member self-management, and connects members to community-based services and resources.

The Population Health Social Worker supports Population Health programs including Transitions of Care, Complex Case Management, Special Needs Plan (SNP) Case Management, Chronic Care Improvement Programs (CCIP), and other care management initiatives. This position serves as the subject matter expert for social determinants of health (SDOH), behavioral health resource coordination, caregiver support, and community partnerships while ensuring compliance with CMS, NCQA, and organizational standards.

Functions & Job Responsibilities

• Conduct comprehensive psychosocial assessments to identify barriers affecting members' health, safety, independence, and overall well-being.
• Assess social determinants of health including housing instability, food insecurity, transportation, financial hardship, caregiver support, social isolation, language barriers, and access to healthcare services.
• Develop individualized care plans that address psychosocial, behavioral, environmental, and community resource needs in collaboration with members, caregivers, and interdisciplinary teams.
• Provide social work consultation for members enrolled in Transitions of Care, Complex Case Management, SNP Case Management, and other Population Health programs.
• Collaborate with Registered Nurses, Care Coordinators, Medical Directors, Primary Care Providers, Behavioral Health providers, Utilization Management, Pharmacy, and community organizations to support comprehensive care planning.
• Facilitate referrals to community-based organizations, government assistance programs, behavioral health services, transportation programs, caregiver resources, home and community-based services, and other available support programs.
• Assist members in accessing Medicare, Medicaid, Social Security, disability benefits, long-term services and supports (LTSS), and other applicable community resources.
• Provide crisis intervention, supportive counseling, motivational interviewing, and problem-solving strategies to assist members experiencing psychosocial challenges.
• Support safe discharge planning and transitions of care by addressing non-clinical barriers that may impact successful recovery and continuity of care.
• Educate members and caregivers regarding available benefits, community resources, advance care planning, caregiver support services, and self-advocacy.
• Participate in interdisciplinary care team (ICT) meetings and contribute psychosocial recommendations that support person-centered care planning.
• Advocate for members to ensure equitable access to medically necessary services and community resources.
• Monitor member progress and reassess psychosocial needs throughout the care management process.
• Maintain accurate, timely, and complete documentation within the care management platform.
• Maintain current knowledge of federal, state, county, and community resources available to Medicare beneficiaries.
• Support quality improvement initiatives, health equity strategies, and organizational performance improvement activities.
• Maintain compliance with CMS Medicare Advantage regulations, NCQA accreditation standards, HIPAA, and applicable federal and state regulations.
• Participate in regulatory audits and documentation reviews as requested.
• Promote culturally responsive, trauma-informed, and member-centered care.
• Perform other duties as assigned.

Qualifications

• Education and Experience

• Master's Degree in Social Work (MSW) from an accredited school of social work required.
• Minimum of three (3) years of social work experience in healthcare, managed care, care management, hospital case management, behavioral health, community health, or related setting.
• Experience working with Medicare, Medicare Advantage, Medicaid, or managed care populations preferred.
• Experience coordinating community resources and addressing social determinants of health required.
• Experience supporting medically complex and vulnerable populations preferred.
• Population Health or Care Management experience preferred.
• Licensed Clinical Social Worker (LCSW) preferred.

Skills

• Knowledge of psychosocial assessment methodologies, crisis intervention, motivational interviewing, and strengths-based care planning.
• Strong knowledge of Medicare Advantage, CMS regulations, NCQA accreditation standards, and Population Health principles.
• Knowledge of social determinants of health, health equity, and community resource navigation.
• Knowledge of behavioral health resources, long-term services and supports (LTSS), caregiver support programs, and public assistance programs.
• Excellent assessment, critical thinking, and problem-solving skills.
• Ability to establish trusting relationships with members, caregivers, providers, and interdisciplinary teams.
• Excellent verbal, written, and interpersonal communication skills.
• Strong organizational and time management skills with the ability to manage multiple priorities.
• Ability to work independently while collaborating effectively within an interdisciplinary care team.
• Proficiency with electronic health records, care management software, Microsoft Office Suite, and virtual communication platforms.
• Ability to maintain confidentiality and comply with HIPAA and organizational privacy requirements.
• Demonstrated commitment to cultural humility, member advocacy, health equity, and continuous quality improvement.
• Bilingual in Mandarin/Cantonese, Vietnamese, Korean, or Spanish preferred.

Wage Range

$73,000 to $85,000 per year

Physical & Working Environment

• Must be able to travel when needed or required
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
• Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Equal Employment Opportunity

Clever Care Health Plan is proud to be an Equal Employment Opportunity andAffirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.