Social Worker (Hybrid)

Job Title: Social Worker
Location: Coral Gables, FL
Pay: Starting from $70,000 per year (based on experience)
Schedule: Full-time, hybrid; 3 days onsite

Travel Requirements: 25–50% road travel within Miami-Dade and Broward Counties

About the Role
Genuine Health Group is seeking an experienced Social Worker to support Medicare/Medicaid beneficiaries with complex medical and psychosocial needs. In this hybrid field/office role, you will complete psychosocial assessments, address social determinants of health (SDOH), coordinate community and medical resources, and collaborate with providers to reduce barriers to care and improve outcomes.

Key Responsibilities

• Perform comprehensive psychosocial assessments in multiple settings (beneficiary homes, clinics, hospitals, SNFs) and document per CMS and organizational standards.
• Identify SDOH barriers (housing, food, transportation, finances, support systems) and connect beneficiaries to appropriate community, state, and federal resources.
• Develop and implement solution-focused care plans in collaboration with beneficiaries, caregivers, and the care team; monitor progress and adjust plans as needed.
• Coordinate care with PCPs, specialists, and internal teams; assist with appointment scheduling and follow-up.
• Provide short-term counseling, crisis intervention, de-escalation, and support during acute events.
• Advocate for beneficiaries, promote empowerment and informed choice, and support health promotion and illness prevention.
• Maintain timely, accurate documentation in the EMR and participate in case conferences, team meetings, and performance improvement activities.
• Ensure all activities comply with HIPAA and organizational policies; maintain active licensure and required training.
• Perform other related duties as assigned.

Required Qualifications

• Master’s degree in Social Work from an accredited school.
• At least 3 years of social work experience in healthcare and/or community settings.
• At least 3 years of experience working with Medicare and/or Medicaid populations.
• Experience with medically complex patients, crisis intervention, and short-term counseling.
• Demonstrated experience addressing social determinants of health (SDOH) and barriers to care.
• Proficiency with EMR documentation and MS Office (Word, Excel, Outlook).
• Reliable transportation and willingness to travel 25-50% within Miami-Dade and Broward counties.

Preferred Qualifications

• Bilingual in English and Spanish.
• Knowledge of population health management and engagement strategies.

Skills and Competencies

• Strong clinical assessment, critical thinking, and decision-making skills.
• Excellent verbal and written communication and documentation skills.
• Relationship-building, conflict management, and de-escalation skills.
• Integrity, compassion, and ability to work independently and as part of a multidisciplinary team.

Work Model

• Hybrid role: onsite 3 days per week in Coral Gables, with field visits across Miami-Dade and Broward counties (patient homes, clinics, hospitals, SNFs).
• Additional in-person attendance at the corporate office as needed for meetings, events, and trainings.

Summary

The Patient Care Navigator is an administrative position that works with the clinical team. The Patient Care Navigator facilitates delivery of information to individual members of the clinical team to help coordinate prescribed healthcare services. Patient Care Navigators are liaisons between beneficiaries/members and healthcare components. In addition, the Patient Care Navigators’ role is to help patients understand treatment plans. Through beneficiary/ member contact, Patient Care Navigators will assist in identifying care gaps in patient care by tracking ordered wellness visits, chronic care management and transition care services. Navigators will report to the Director of Clinical Operations. Patient Care Navigators will not recommend or render any medical services.

Essential Duties and Responsibilities

• Increases involvement of the beneficiary/member and or their caregiver in the decision-making process.
• Minimizes fragmentation of care within the healthcare delivery system.
• Assists in improving adherence to the plan of care for the beneficiary.
• Assists beneficiary/member by acting as an advocate.
• Collaborates with clinical teams to focus on moving the beneficiary/member to self-care (independence) whenever possible.
• Assists in coordinating care for beneficiary/member, including chronic care management and transition care management.
• Participates in team meetings and quality improvement initiative.
• Focuses on transitions of care, which includes a complete transfer from one care setting to the next that is safe, effective, and timely.
• Collaborates with outpatient staff to ensure that safe transition to the new care setting and follow up with the primary care physician and/or specialist.
• Improves outcomes by utilizing adherence guidelines, standardized tools, and proven processes to measure a beneficiary/member’s understanding and acceptance of the proposed plans, his/her willingness to change, and his/her support to maintain health behavior change.
• Facilitates health and disease beneficiary/member education.
• Coordinates with clinical teams with the goal of moving beneficiary to optimal levels of health and well-being.
• Improves beneficiary/member safety and satisfaction with their healthcare needs.
• Expands the interdisciplinary team to include beneficiary/member and or their identified support system, healthcare providers; including community based and facility-based professionals (i.e. pharmacists, Medical Social Workers, holistic care providers).
• Improves beneficiary/member experience by coordinating appointments and referrals with specialists using our Preferred Provider Network.
• Maintains a daily census of beneficiaries/members’ admissions, discharge dispositions.
• Demonstrates proficiency with electronic medical records and care coordination systems.
• Documents all interactions between beneficiary/member/ caregiver and all components of the healthcare delivery system.
• Adheres to all policies and procedures including but not limited to the HIPAA Privacy rule.
• Performs other duties as assigned.

Knowledge, Skills and Abilities

• Knowledge with Care Coordination of the elderly.
• Ability to work with a high attention to detail.
• Compassion and empathy.
• Strong communication and interpersonal skills; both written and oral.
• Proficiency with electronic healthcare records systems.
• Proficiency in Excel and Word.
• Minimum Education and Experience.

Education

• High School diploma
• Driver’s license
• Preferred One (1) year of outpatient or inpatient care setting experience
• Fully bilingual preferred (English/Spanish)

Summary

The Patient Care Navigator is an administrative position that works with the clinical team. The Patient Care Navigator facilitates delivery of information to individual members of the clinical team to help coordinate prescribed healthcare services. Patient Care Navigators are liaisons between beneficiaries/members and healthcare components. In addition, the Patient Care Navigators’ role is to help patients understand treatment plans. Through beneficiary/ member contact, Patient Care Navigators will assist in identifying care gaps in patient care by tracking ordered wellness visits, chronic care management and transition care services. Navigators will report to the Director of Clinical Operations. Patient Care Navigators will not recommend or render any medical services.

Essential Duties and Responsibilities

• Increases involvement of the beneficiary/member and or their caregiver in the decision-making process.
• Minimizes fragmentation of care within the healthcare delivery system.
• Assists in improving adherence to the plan of care for the beneficiary.
• Assists beneficiary/member by acting as an advocate.
• Collaborates with clinical teams to focus on moving the beneficiary/member to self-care (independence) whenever possible.
• Assists in coordinating care for beneficiary/member, including chronic care management and transition care management.
• Participates in team meetings and quality improvement initiative.
• Focuses on transitions of care, which includes a complete transfer from one care setting to the next that is safe, effective, and timely.
• Collaborates with outpatient staff to ensure that safe transition to the new care setting and follow up with the primary care physician and/or specialist.
• Improves outcomes by utilizing adherence guidelines, standardized tools, and proven processes to measure a beneficiary/member’s understanding and acceptance of the proposed plans, his/her willingness to change, and his/her support to maintain health behavior change.
• Facilitates health and disease beneficiary/member education.
• Coordinates with clinical teams with the goal of moving beneficiary to optimal levels of health and well-being.
• Improves beneficiary/member safety and satisfaction with their healthcare needs.
• Expands the interdisciplinary team to include beneficiary/member and or their identified support system, healthcare providers; including community based and facility-based professionals (i.e. pharmacists, Medical Social Workers, holistic care providers).
• Improves beneficiary/member experience by coordinating appointments and referrals with specialists using our Preferred Provider Network.
• Maintains a daily census of beneficiaries/members’ admissions, discharge dispositions.
• Demonstrates proficiency with electronic medical records and care coordination systems.
• Documents all interactions between beneficiary/member/ caregiver and all components of the healthcare delivery system.
• Adheres to all policies and procedures including but not limited to the HIPAA Privacy rule.
• Performs other duties as assigned.

Knowledge, Skills and Abilities

• Knowledge with Care Coordination of the elderly.
• Ability to work with a high attention to detail.
• Compassion and empathy.
• Strong communication and interpersonal skills; both written and oral.
• Proficiency with electronic healthcare records systems.
• Proficiency in Excel and Word.
• Minimum Education and Experience.

Education

• High School diploma
• Driver’s license
• Preferred One (1) year of outpatient or inpatient care setting experience
• Fully bilingual preferred (English/Spanish)

Genuine Health Group offers a competitive compensation and benefits package that includes a 401k matching program, fully subsidized medical plans, paid holidays and much more. Base salary will be commensurate to professional experience. All final employment offers are contingent upon successful completion of background checks.

Genuine Health Group is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Job Type: Full-time

Pay: From $70,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Application Question(s):

• Will you now or in the future require sponsorship for employment visa status (e.g., H-1B, TN, OPT, etc.)?
• Do you have experience with long-term placement and long-term placement application?
• This hybrid position requires onsite responsibilities. Are you within reasonable commuting distance to Coral Gables, Florida?
• What are your salary expectations?

Education:

• Master's (Required)

Experience:

• Social Work: 3 years (Required)
• Medicare/Medicare Advantage/Medicaid: 3 years (Required)

Language:

• English and Spanish (Preferred)

Willingness to travel:

• 50% (Required)

Work Location: Hybrid remote in Coral Gables, FL 33134

Salary : $70,000