Medical Social Worker

Overview

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.

• Direct Family Member Support:
  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.

• Consultative & Interdisciplinary Support:
  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.

• Resource Development & Management:
  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.

• Documentation, Compliance & Reporting:
  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.

• Program Support & Continuous Improvement:
  Identify systemic gaps in available social resources and escalate 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.

• 3+ years of experience providing social work services in healthcare, care management, or community-based settings.
• Experience addressing complex social determinants of health for medically and socially complex populations.
• Experience working with interdisciplinary care teams preferred.

• Skills:
  • Strong assessment, care coordination, and advocacy skills.
  • Knowledge of healthcare payer benefits, community-based resources, and social service systems.
  • Excellent communication and documentation skills.
  • Ability to work independently and collaboratively in remote and field-based environments.
  • Proficiency with electronic health records (EHRs) and care management platforms.
  • Ability to conduct community-based services assessments, including evaluation of local resource availability, service capacity, eligibility criteria, and gaps impacting family member access to care.
  • Bilingual candidates strongly preferred.

Work is performed indoors in a setting with air conditioning and artificial light. Travel to and work in offices or other environments is required. You will need to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common.

Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 10 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize…