Primary Care HIV Clinic Social Worker (3410)

Job DetailsJob Location

• Central -
• 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