Central Health

Medical Social Worker - Care Management

Req No.
CommUnityCare Health Centers
South Austin
2529 S. First St.
South Austin
Medical Services
Regular Full-Time


In collaboration with patients, families (as defined by patient) and staff across all disciplines and departments, the Medical Social Worker is responsible for applying empowerment-based prevention and intervention strategies to improve community health, making referrals to community based resources, addressing barriers to improving well-being, offering expertise regarding psycho-social issues affecting patient care, and educating patients regarding illness and treatment options.


  • Apply empowerment-based prevention and intervention strategies to improve community health.
  • Research and provide referrals for patients to appropriate, accessible community-based resources.
  • Assess individual needs, strengths, barriers, and readiness to change.
  • Address personal and environmental issues with the patient in order to maximize emotional, social, and physical wellbeing and the appropriate use of healthcare resources.
  • Offer the “person-in-environment” perspective, which incorporates all factors that influence a patient’s health care experience.
  • Help patients and families understand illness and treatment options, as well as consequences of various treatments or treatment refusal.
  • Provide the expertise, consultation, and education in areas relating to psycho-social issues affecting patient care.
  • Communicate and collaborate with clinic providers and support staff to assess patient’s needs and provide comprehensive healthcare.
  • Seek opportunities and implement goals for own professional development.
  • Complete all direct and indirect care documentation in timely manner and ensure patient records are current and complete.
  • Attend patient care (unit) huddles and periodic informational (clinic) huddles, meetings, patient conferences, or planning sessions. These may be related to quality assurance, patient care and other related topics within the clinic
  • Attend seminars and maintain all licensure and/or certification requirements for continuing education and best practices.
  • Participate in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes.
  • Ensure all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards including The Joint Commission and CommUnityCare Standard Operating Procedures and CommUnityCare Policies and Procedures.
  • Develop and maintain favorable internal relationships, partnerships with co-workers, including clinical managers, clinical support staff, providers and business office staff.
  • Interact respectfully and collaboratively with patients and their families, striving to develop favorable relationships with families.
  • Collaborate with all members of the care team in providing patient-centered care.
  • Perform other duties as assigned.


  • High level of skill at building relationships and providing excellent customer service.
  • High degree of knowledge and competency in mental health treatment plans.
  • High level of problem solving skill to better serve patients and staff.
  • Strong attention to detail and accuracy.
  • Excellent verbal and written communication skills.
  • Demonstrated knowledge of community resources available and how to access resources for the benefit of clients.
  • Demonstrated experience conducting social work services in both individual and group settings.
  • Demonstrated success in collaborating with other healthcare providers for patient-centered care.
  • Bilingual preferred.


MINIMUM EDUCATION:  Master’s degree in Social Work (MSW)


MINIMUM EXPERIENCE:  1 Year as Licensed Masters Social Worker (LMSW)

PREFERRED EXPERIENCE:  2 Years as Licensed Master Social Worker (LMSW)


  • Licensed Master Social Worker (LMSW)


  • Licensed Clinical Social Worker (LCSW)


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