Job Description

Population Healthcare Social Worker

Description

Social Worker – Population Health

Company: Community Care Plan Location: Sunrise, Florida

Schedule: Hybrid – Day Shift Employment Type: Full Time

Join our Care Coordination Concierge team and make a meaningful impact on patient lives.

We’re looking for a compassionate and skilled Social Worker to support high-risk patients through personalized care coordination, psychosocial assessments, and community resource connections. You’ll be part of a dynamic, interdisciplinary team focused on improving outcomes for individuals with complex health and social needs.

What You’ll Do

• Deliver personalized psychosocial support and connect patients to essential community resources.
• Conduct comprehensive assessments to identify barriers to care, including social determinants of health.
• Develop and monitor care plans in collaboration with patients, families, and care teams.
• Standardized Post-Discharge Assessments:
• Conduct comprehensive, standardized post-discharge assessments to ensure patients experience a safe and seamless transition of care, from inpatient care to their home or community setting, as well as to identify ongoing support needs, and comply with quality performance measures. This assessment aim to:
• Engage and educate patients and caregivers on self-management, chronic condition support, and available services.
• Participate in interdisciplinary team meetings to coordinate high-quality, patient-centered care .
• Improve Patient Education and Self-Management: Provide tailored guidance on managing chronic conditions , recognizing warning signs, and accessing available resources to promote patient independence.
• Maintain detailed documentation that supports care planning, regulatory compliance, and performance goals.

Who You Are

• A self-motivated, empathetic professional with strong communication and collaboration skills.
• Experienced in navigating complex healthcare systems and social services.
• Able to think critically and adapt in fast-paced, patient-focused environments.
• Knowledgeable in managed care, Medicaid/Social Security, and local community resources.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.

Qualifications:

Preferred Qualifications

• Minimum of a master’s degree in Social Work (MSW)

Certificates & Licenses :

• LCSW Licensure in State of Florida (preferred)
• State Licensure - Must meet the state-specific licensure requirements for social workers
• Certified Case Manager (CCM®) preferred
• Certification in Population Health or Health Coaching (Preferred)

Experience:

• Social Work Experience: minimum of 3-5 years related field
• Experience in Managed Care/Health Plan Setting: 3-5 years of experience in a managed care, health plan, or insurance setting.
• Experience with Utilization Management and Care Coordination: Experience coordinating care across medical, behavioral, and social service providers, including familiarity with utilization management processes, appeals, and authorizations.
• Knowledge of Medicaid/Medicare Regulations: Experience working with Medicaid, Medicare, or other state and federal health care programs, including knowledge of relevant regulations and compliance requirements.
• Knowledge of Microsoft Office and internet software
• Knowledge of EPIC and/or JIVA (preferred)

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