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Interdisciplinary Care Integration Team (CIT)

The LCSW serves as a core member of the Care Integration Team, supporting complex, high-risk patients through proactive psychosocial assessment, short-term interventions, and connection to community-based resources. This role brings behavioral health expertise and addresses social determinants of health to improve access, engagement, and outcomes.

This role requires a deep understanding of how socio-economic, behavioral, and environmental factors impact a patient’s ability to engage in healthcare and influence health outcomes. Ideal experience includes prior work in primary care or working as part of an interdisciplinary team—particularly in partnership with primary care teams, community health workers, pharmacists, and behavioral health specialists.

Duties and Responsibilities

+ Conducts comprehensive assessment of behavioral health needs and formulates diagnosis, treatment plan, goals for next steps for patient care

+ Employs a variety of strategies, approaches, and modalities to address acute behavioral health symptoms, with a focus on CBT, motivational interviewing, solution-focused, and mindfulness techniques

+ Identifies barriers that hinder effective engagement

+ Focuses on patients’ high-risk symptoms or frequent hospital utilizers to identify ways to extend wellness and decrease utilization.

+ Ensures patient progression towards desired outcomes by monitoring symptom progression through scheduled visits

+ LCSW offers recommendations to providers about external behavioral health resources, SDOH needs, and other community partners which may support patient needs.

+ Participates in care planning process within multidisciplinary team to collaboratively address patient needs

+ Attends high-risk rounds as an active participant, making BH recommendations and supporting high risk patients.

+ Provides support and guidance to patients and families through advance care planning discussions as indicated

+ Assists teams, primary care centers, patients, and other staff with suicide risk assessment review, next steps, and guidance.

+ Assists patients expressing suicidal thoughts as needed.

+ Covers other LCSWs in the state of licensure to address patient care when teammates are on PTO.

+ Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas

+ LCSW will adhere to recommended visits per day

Use your skills to make an impact

Required Qualifications

+ Master’s degree in social work (MSW)

+ Licensed Clinical Social Work License (LCSW) in Florida

+ Willingness to obtain licensure in additional states as needed

+ Minimum of 4-years’ experience working as a Clinical Social Worker

+ Knowledge of community health and social service agencies as well as behavioral health resources

+ Knowledge of mental health needs, assessment, developing treatment plans and goals, and ability to function independently in LCSW role.

+ Familiarity with electronic medical record EMR documentation

Preferred Qualifications

+ Experience working with the geriatric/senior population

+ Experience working on a collaborative team (disciplines of nurses, social workers, providers, etc.)

+ Bilingual English/Spanish (ability to read, write and speak)

+ Experience conducting diagnostic assessments

+ Experience in crisis management and intervention

Environmental / Working Conditions: Virtual/Work at Home

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.

Satellite, cellular and microwave connection can be used only if approved by leadership.

Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.

Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Scheduled Weekly Hours

40 hours, 8am to 5pm

Benefits

Health benefits effective day 1

Paid time off, holidays, volunteer time and jury duty pay

Recognition pay

401(k) retirement savings plan with employer match

Tuition assistance

Scholarships for eligible dependents

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$65,000 - $88,600 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being.

About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

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Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources