Primary Care HIV Clinic Social Worker

WACO FAMILY MEDICINE•Waco, TX

4d•Onsite

About The Position

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.

Requirements

Licensed Master Social Worker (LMSW) required
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
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

Nice To Haves

Experience in social services, counseling, case management, or vocational rehabilitation
Social work services in healthcare or integrated care settings

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