This position operates on a hybrid work schedule. This position will require 3 days onsite at the Monrovia or Huntington Beach office.
Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.
Who Are We?
Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.
Why Join Us?
We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.
Job Summary
The Population Health Social Worker is responsible for providing comprehensive psychosocial assessment, care coordination, advocacy, and resource navigation for Medicare Advantage members with complex medical, behavioral, functional, and social needs. Working collaboratively with interdisciplinary teams, the Population Health Social Worker addresses psychosocial barriers that impact health outcomes, supports safe transitions of care, promotes member self-management, and connects members to community-based services and resources.
The Population Health Social Worker supports Population Health programs including Transitions of Care, Complex Case Management, Special Needs Plan (SNP) Case Management, Chronic Care Improvement Programs (CCIP), and other care management initiatives. This position serves as the subject matter expert for social determinants of health (SDOH), behavioral health resource coordination, caregiver support, and community partnerships while ensuring compliance with CMS, NCQA, and organizational standards.
Functions & Job Responsibilities
- Conduct comprehensive psychosocial assessments to identify barriers affecting members' health, safety, independence, and overall well-being.
- Assess social determinants of health including housing instability, food insecurity, transportation, financial hardship, caregiver support, social isolation, language barriers, and access to healthcare services.
- Develop individualized care plans that address psychosocial, behavioral, environmental, and community resource needs in collaboration with members, caregivers, and interdisciplinary teams.
- Provide social work consultation for members enrolled in Transitions of Care, Complex Case Management, SNP Case Management, and other Population Health programs.
- Collaborate with Registered Nurses, Care Coordinators, Medical Directors, Primary Care Providers, Behavioral Health providers, Utilization Management, Pharmacy, and community organizations to support comprehensive care planning.
- Facilitate referrals to community-based organizations, government assistance programs, behavioral health services, transportation programs, caregiver resources, home and community-based services, and other available support programs.
- Assist members in accessing Medicare, Medicaid, Social Security, disability benefits, long-term services and supports (LTSS), and other applicable community resources.
- Provide crisis intervention, supportive counseling, motivational interviewing, and problem-solving strategies to assist members experiencing psychosocial challenges.
- Support safe discharge planning and transitions of care by addressing non-clinical barriers that may impact successful recovery and continuity of care.
- Educate members and caregivers regarding available benefits, community resources, advance care planning, caregiver support services, and self-advocacy.
- Participate in interdisciplinary care team (ICT) meetings and contribute psychosocial recommendations that support person-centered care planning.
- Advocate for members to ensure equitable access to medically necessary services and community resources.
- Monitor member progress and reassess psychosocial needs throughout the care management process.
- Maintain accurate, timely, and complete documentation within the care management platform.
- Maintain current knowledge of federal, state, county, and community resources available to Medicare beneficiaries.
- Support quality improvement initiatives, health equity strategies, and organizational performance improvement activities.
- Maintain compliance with CMS Medicare Advantage regulations, NCQA accreditation standards, HIPAA, and applicable federal and state regulations.
- Participate in regulatory audits and documentation reviews as requested.
- Promote culturally responsive, trauma-informed, and member-centered care.
- Perform other duties as assigned.