Medical Social Worker

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical delivering improved health outcomes.

By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

The Medical Social Worker provides direct and consultative support to address complex Social Determinants of Health (SDOH) needs for Grace at Home family members. This role partners with interdisciplinary care teams to assess social risk, develop intervention plans, and connect family members to appropriate healthcare payor and community-based resources. The Medical Social Worker builds and maintains a comprehensive resource database to support scalable, high-quality social care interventions.

This position plays a critical role in improving access, care coordination, and outcomes for individuals with complex social needs.

• Provide direct social work services to family members with complex SDOH needs identified through interdisciplinary care teams.
• Conduct psychosocial assessments to identify barriers related to housing, food insecurity, transportation, financial strain, caregiver support, behavioral health access, and other social drivers of health.
• Develop individualized care and resource plans in collaboration with family members, caregivers, and clinical teams.
• Provide ongoing follow-up, advocacy, and care coordination to support successful resolution of identified social needs.

• Serve as a subject matter expert for SDOH, providing consultation and guidance to interdisciplinary care teams.
• Participate in case conferences and care planning discussions to support holistic, patient-centered care.
• Recommend appropriate social care interventions aligned with clinical and care management goals.

• Build, maintain, and continuously update a comprehensive database of healthcare payer benefits, community-based organizations, and social service resources.
• Establish relationships with community partners, social service agencies, and payer representatives to enhance referral pathways.
• Ensure resource information is accurate, accessible, and aligned with eligibility and referral requirements.

• Document all assessments, interventions, referrals, and outcomes in designated systems in accordance with organizational, regulatory, and payer requirements.
• Track and report SDOH needs, interventions, and outcomes to support value-based care (VBC) contracts, quality initiatives, and payer reporting requirements.
• Support SDOH-related reporting for value-based programs, including ACOs, MSSP, HEDIS, and other payer-specific initiatives, as applicable.
• Ensure accurate capture of social risk factors, interventions, and resolutions to support quality measurement, risk stratification, and total cost of care analyses.
• Collaborate with analytics, quality, and clinical teams to validate SDOH data and improve reporting accuracy and completeness.

• Identify systemic gaps in available social resources and elevate trends to leadership.
• Contribute to the development of workflows, tools, and best practices for SDOH support across the organization.
• Stay current on emerging SDOH models, community resources, and regulatory requirements.
• Perform other job-related duties as assigned.

• Education:
  
  Master’s degree in Social Work (MSW) from an accredited program required.
• Experience:
  • 3+ years of experience providing social work services in…