Primary Care HIV Clinic Social Worker

Job DetailsJob Location: Waco, TX 76707Position Type: Full TimeEducation Level: Graduate DegreeTravel Percentage: Up to 25%Job Shift: DayJob Category: Health CarePosition 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  Qualifications  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