Primary Care HIV Clinic Social Worker (3410)

Position Summary 

The Social Work Care Manager provides comprehensive care coordination and psychosocial support for high-risk patients to improve health outcomes, enhance self-management, and reduce avoidable healthcare utilization. The role integrates medical, behavioral, and social care through assessment, care planning, patient coaching, and coordination with internal and community resources. 

Essential Functions and Responsibilities 

• Coordinate and manage care for high-risk patients across medical, behavioral health, and community services 

• Develop and maintain tracking systems to support seamless care coordination, referrals, and care transitions 

• Identify and address care gaps through proactive outreach and follow-up 

• Implement standing delegated orders and care management protocols 

• Participate in and/or lead interdisciplinary Care Team meetings 

• Serve as liaison among primary care, specialty, and behavioral health providers 

• Conduct comprehensive psychosocial and health needs assessments 

• Develop individualized care plans emphasizing prevention, stabilization, and self-management 

• Apply knowledge of chronic medical and behavioral conditions in care planning 

• Monitor patient progress and adjust care plans accordingly 

• Provide coaching and education to support chronic disease self-management 

• Utilize evidence-based behavioral strategies (e.g., motivational interviewing) 

• Assist patients in navigating the healthcare system and accessing specialty services 

• Identify and connect patients with appropriate community and social resources 

• Address social determinants of health affecting care adherence and outcomes 

• Coordinate services that improve safety, stability, and quality of life 

• Maintain accurate documentation and care management records 

• Contribute to program tracking and quality improvement activities 

• Perform other duties as assigned 

  Reports To: Director of Care Management and Social Work Care Management Team Lead 

Qualifications 

• Licensed Master Social Worker (LMSW) required 

• Preferred: Experience in social services, counseling, case management, or vocational rehabilitation 

• Preferred: Social work services in healthcare or integrated care settings 

• Care management and care plan development 

• Interdisciplinary collaboration 

• Psychosocial assessment and screening 

• Chronic disease and behavioral health knowledge 

• Motivational interviewing and patient engagement 

• Strong written and verbal communication 

• Professional interaction with healthcare teams 

Physical and Environmental Requirements 

• Valid Texas driver’s license and personal transportation with liability insurance 

• Primarily indoor clinical/office environment 

• Prolonged sitting and computer use 

• Frequent telephone and device use 

• Occasional walking, bending, kneeling, reaching 

• Occasional lifting/carrying up to 25 lbs 

• Ability to understand and execute detailed instructions 

• Physical accommodations provided when feasible