Internal Application: Medical Social Worker

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.

Overview

The Medical Social Worker provides direct and consultative support to address complex Social Determinants of Health (SDOH) needs for Grace at Home family members. This role partners with interdisciplinary care teams to assess social risk, develop intervention plans, and connect family members to appropriate healthcare payor and community-based resources. The Medical Social Worker builds and maintains a comprehensive resource database to support scalable, high-quality social care interventions. This position plays a critical role in improving access, care coordination, and outcomes for individuals with complex social needs.

Duties & Responsibilities

Direct Family Member Support

• Provide direct social work services to family members with complex SDOH needs identified through interdisciplinary care teams.
• Conduct psychosocial assessments to identify barriers related to housing, food insecurity, transportation, financial strain, caregiver support, behavioral health access, and other social drivers of health.
• Develop individualized care and resource plans in collaboration with family members, caregivers, and clinical teams.
• Provide ongoing follow-up, advocacy, and care coordination to support successful resolution of identified social needs.

Consultative & Interdisciplinary Support

• Serve as a subject matter expert for SDOH, providing consultation and guidance to interdisciplinary care teams.
• Participate in case conferences and care planning discussions to support holistic, patient-centered care.
• Recommend appropriate social care interventions aligned with clinical and care management goals.

Resource Development & Management

• Build, maintain, and continuously update a comprehensive database of healthcare payer benefits, community-based organizations, and social service resources.
• Establish relationships with community partners, social service agencies, and payer representatives to enhance referral pathways.
• Ensure resource information is accurate, accessible, and aligned with eligibility and referral requirements.

Documentation, Compliance & Reporting

• Document all assessments, interventions, referrals, and outcomes in designated systems in accordance with organizational, regulatory, and payer requirements.
• Track and report SDOH needs, interventions, and outcomes to support value-based care (VBC) contracts, quality initiatives, and payer reporting requirements.
• Support SDOH-related reporting for value-based programs, including ACOs, MSSP, HEDIS, and other payer-specific initiatives, as applicable.
• Ensure accurate capture of social risk factors, interventions, and resolutions to support quality measurement, risk stratification, and total cost of care analyses.
• Collaborate with analytics, quality, and clinical teams to validate SDOH data and improve reporting accuracy and completeness.

Program Support & Continuous Improvement

• Identify systemic gaps in available social resources and escalate trends to leadership.
• Contribute to the development of workflows, tools, and best practices for SDOH support across the organization.
• Stay current on emerging SDOH models, community resources, and regulatory requirements.
• Perform other job-related duties as assigned.

Qualifications

• Education: Master’s degree in Social Work (MSW) from an accredited program required.

  Experience:

  • 3+ years of experience providing social work services in healthcare, care management, or community-based settings.
  • Experience addressing complex social determinants of health for medically and socially complex populations.
  • Experience working with interdisciplinary care teams preferred.

• Skills:

  • Strong assessment, care coordination, and advocacy skills.
  • Knowledge of healthcare payer benefits, community-based resources, and social service systems.
  • Excellent communication and documentation skills.
  • Ability to work independently and collaboratively in remote and field-based environments.
  • Proficiency with electronic health records (EHRs) and care management platforms.
  • Ability to conduct community-based services assessments, including evaluation of local resource availability, service capacity, eligibility criteria, and gaps impacting family member access to care.
  • Bilingual candidates strongly preferred.

The working environment and physical requirements of the job include:

Work is performed indoors in a setting with air conditioning and artificial light. Travel to and work in offices or other environments is required. 

In this position you will need to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 10 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.

Equal Opportunity & Reasonable Accommodation Statement

Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.

If you require reasonable accommodation during the application or employment process, please inform the recruiter during the hiring process.

Disclaimer

This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, and skills required. Management reserves the right to modify, add, or remove duties as necessary.

Our Benefits

Financial Well-being

• Competitive Compensation: We offer competitive salaries to attract and retain the best talent.
• 401(k) with Employer Match: Plan for your future with our 401(k) plan and a generous 4% employer match.

Health and Wellness

• Comprehensive Medical Plan: We proudly offer a comprehensive medical option with an employer contribution.
• Dental & Vision Coverage: Maintain your oral and eye health with our employer-paid dental and vision plans via MetLife.
• Employer-Paid Insurance: Life, Short-Term Disability (STD), and Long-Term Disability (LTD) insurance are provided at no cost to you.
• Generous Paid Time Off: Enjoy ample time off for rest and rejuvenation with generous PTO, holidays, and wellness time.

Additional Perks

• Continuing Medical Education (CME) Allowance for APPs: Stay at the forefront of your field with our CME allowance.
• Commuter Benefits: Save on your commute with our commuter benefits program.
• Mileage Reimbursement: Get reimbursed for work-related travel expenses.