CenterWell Senior Primary Care
Join to apply for the
MSW Care Navigator
role at
CenterWell Senior Primary Care .
Pay Range This role offers an annual salary ranging from $65,000 to $88,600. Actual pay will be based on your skills, experience, and qualifications.
Job Functions & Responsibilities Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging high‑risk patients and implementing targeted interventions to address social needs and increase access to care. The role requires an understanding of how socio‑economic stressors impact patients’ ability to engage in healthcare and subsequent health outcomes.
Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow‑ups.
Provide triage guidance and supportive consultation to other team members, handling escalated complex cases.
Develop care plans leveraging the 5Ms Geriatric best practice framework.
Develop a holistic view of patient needs related to Social Determinants of Health.
Identify existing barriers to engagement with necessary resources and supports.
Provide education around maintenance of chronic health conditions, behavioral care options, and social support.
Serve as liaison between the patient and direct care providers, assisting in navigating internal and external systems.
Initiate care planning and subsequent action steps for high‑risk members, coordinating with interdisciplinary team.
Support patients’ self‑determination and motivate them to meet identified health goals.
Refer patients to necessary services and supports.
Assist with transportation, food insecurity, benefits applications (e.g., Medicaid, HCBS), prescription medication cost reduction, scheduling follow‑up appointments, and alleviating social isolation.
Lead interdisciplinary team meetings when indicated.
Assess patient’s family system; conduct family meetings with patient and family when needed.
Participate in creating and facilitating team training content.
Conduct psycho‑education and support groups within the Center.
Participate in interdisciplinary reviews and coordination around complex patients.
Maintain patient confidentiality in accordance with HIPAA.
Document patient encounters in the medical record system timely.
Follow general policies related to fire safety, infection control, and attendance.
Required Qualifications
Master’s Degree in Social Work.
Minimum of four years of experience working in healthcare services and navigating community‑based resources.
Preferred Qualifications
Licensed Master Social Worker.
Familiarity with state Medicaid guidelines and application processes.
Experience working with patients with behavioral health conditions and substance use disorders.
Prior experience conducting home visits and knowledge of field safety practices.
Skills & Competencies Required
Advanced clinical acumen.
Ability to multi‑task in a fast‑paced work environment.
Flexibility to transition and adjust in an evolving role.
Excellent organizational skills.
Advanced oral and written communication skills.
Strong interpersonal and relationship building skills.
Compassion and advocacy for patient needs.
Critical thinking and problem‑solving capabilities.
Working Conditions This role has a mobile presence, involving travel to patients’ homes, treatment facilities, and community‑based settings, as well as assigned clinics.
Location Must reside in the Atlanta, GA metro area.
Hours Must be able to work a 40‑hour workweek, Monday through Friday 8:00 AM to 5:00 PM. Overtime may be requested to meet business needs.
Tuberculosis (TB) Screening This role is member‑facing and part of Humana’s TB screening program. Candidates selected for this role will be required to undergo TB screening.
Benefits
Health benefits effective day one.
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.
Short‑term and long‑term disability.
Life insurance.
Other benefits as outlined by Humana.
Equal Opportunity Employer Humana does not discriminate against any employee or applicant for employment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status, and it takes affirmative action in compliance with applicable laws.
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MSW Care Navigator
role at
CenterWell Senior Primary Care .
Pay Range This role offers an annual salary ranging from $65,000 to $88,600. Actual pay will be based on your skills, experience, and qualifications.
Job Functions & Responsibilities Working within an interdisciplinary care team, the Care Navigator is responsible for proactively engaging high‑risk patients and implementing targeted interventions to address social needs and increase access to care. The role requires an understanding of how socio‑economic stressors impact patients’ ability to engage in healthcare and subsequent health outcomes.
Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow‑ups.
Provide triage guidance and supportive consultation to other team members, handling escalated complex cases.
Develop care plans leveraging the 5Ms Geriatric best practice framework.
Develop a holistic view of patient needs related to Social Determinants of Health.
Identify existing barriers to engagement with necessary resources and supports.
Provide education around maintenance of chronic health conditions, behavioral care options, and social support.
Serve as liaison between the patient and direct care providers, assisting in navigating internal and external systems.
Initiate care planning and subsequent action steps for high‑risk members, coordinating with interdisciplinary team.
Support patients’ self‑determination and motivate them to meet identified health goals.
Refer patients to necessary services and supports.
Assist with transportation, food insecurity, benefits applications (e.g., Medicaid, HCBS), prescription medication cost reduction, scheduling follow‑up appointments, and alleviating social isolation.
Lead interdisciplinary team meetings when indicated.
Assess patient’s family system; conduct family meetings with patient and family when needed.
Participate in creating and facilitating team training content.
Conduct psycho‑education and support groups within the Center.
Participate in interdisciplinary reviews and coordination around complex patients.
Maintain patient confidentiality in accordance with HIPAA.
Document patient encounters in the medical record system timely.
Follow general policies related to fire safety, infection control, and attendance.
Required Qualifications
Master’s Degree in Social Work.
Minimum of four years of experience working in healthcare services and navigating community‑based resources.
Preferred Qualifications
Licensed Master Social Worker.
Familiarity with state Medicaid guidelines and application processes.
Experience working with patients with behavioral health conditions and substance use disorders.
Prior experience conducting home visits and knowledge of field safety practices.
Skills & Competencies Required
Advanced clinical acumen.
Ability to multi‑task in a fast‑paced work environment.
Flexibility to transition and adjust in an evolving role.
Excellent organizational skills.
Advanced oral and written communication skills.
Strong interpersonal and relationship building skills.
Compassion and advocacy for patient needs.
Critical thinking and problem‑solving capabilities.
Working Conditions This role has a mobile presence, involving travel to patients’ homes, treatment facilities, and community‑based settings, as well as assigned clinics.
Location Must reside in the Atlanta, GA metro area.
Hours Must be able to work a 40‑hour workweek, Monday through Friday 8:00 AM to 5:00 PM. Overtime may be requested to meet business needs.
Tuberculosis (TB) Screening This role is member‑facing and part of Humana’s TB screening program. Candidates selected for this role will be required to undergo TB screening.
Benefits
Health benefits effective day one.
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.
Short‑term and long‑term disability.
Life insurance.
Other benefits as outlined by Humana.
Equal Opportunity Employer Humana does not discriminate against any employee or applicant for employment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or protected veteran status, and it takes affirmative action in compliance with applicable laws.
#J-18808-Ljbffr