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