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Texas Health Resources Community Social Worker – Farmers Branch, TX SWHR CIN in Dallas, Texas

Southwestern Health Resources (SWHR CIN) seeks to hire a Community Social Worker to work Full Time supporting the Care Coordination department.

Please note: Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is an affiliated company of Texas Health and UT Southwestern. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health or UT Southwestern employee.

The address is 8150 Brookriver Drive, Dallas, Texas 75247

After SWHR Covid protocol ends, this position will office at the SWHR Corporate Headquarters, 1603 LBJ Freeway, Farmers Branch, Texas 75234

Salary range is Min $27.00 - Max $45.38 – based on relevant experience

Work Schedule

Monday-Friday, 8am-5pm

Job Description

Asses the biopsychosocial status of identified patients in the home or other settings initiating appropriate community referrals in addition to providing supportive counseling services to patients, families, and caregivers.

Community referrals include, but not limited to, provision of nutrition, prescription assistance, transportation, housing and rent assistance, and custodial in-home care.

Community social worker in collaboration with patient's medical home physician and team will assist with direct skilled nursing placement, arranging home health, arranging provider home visits, and hospice.

Conduct home, primary care clinic, and skilled facility visits as necessary developing a written plan to provide information and direction to the other health team members.

Interview patients, their families, and other concerned parties to obtain information about personal, social, and environmental history. Evaluate social functioning, particularly as it relates to medical problems, initiation, and follow-up of referrals to other resources.

Facilitate and manage referrals accordingly to ensure continuity of services.

Provide patient and family counseling for adjustment issues, grief, and end of life issues.

Provide support to patients and their families when personal, social or environmental difficulties exist which predispose illness or interfere with obtaining maximum benefits from medical or mental healthcare.

Chronic disease self-management - Instructing on coping strategies including planning, behavior modeling, problem solving techniques, and decision making related to managing chronic diseases.

Assess when appropriate, a patient and/or family's financial situation taking into consideration the patient's diagnosis, prognosis and medical needs, and refer to an agency for financial assistance if indicated, interpret the medical situation to the referring agency and generally facilitate the process of referral; advise, counsel, and when appropriate, instruct the patient and family in the patient's social needs; provide advanced care planning education, documents, and assistance with completion of directive to physicians, medical power of attorney, and out of hospital do no resuscitate.

Coordinate with the patient, physician, and pharmaceutical company to provide prescription assistance.

Provide social work services to Extensivist Physician panel as needed

Participate in medical home, staff conferences presenting case histories; confer with other members of the medical home team to develop comprehensive evaluations or plans providing maximum benefits for each patient.

Assist in interdisciplinary team meetings in meeting the psycho-social needs of patients to enable patient to utilize medical, mental health, and community services. Assist the primary care physician and other team members in understanding the significant social and emotional factors related to the patient's medical diagnosis.

Assist patients and their families, through individual or group conferences, to understand, accept, and follow services planned to improve and restore patients to optimum social, medical, and mental health.

Maintain familiarity with community resources and agencies for assigned zone, local, and nationally updating resources as necessary Maintain professional relationships with other agencies and acts as an affiliate with community agencies; participate in area/ zone activities related to health and community services.

Assist in the planning and implementation of special seminars and forums as needed.

Observe, record, and report information on the patient's condition to the primary care physician or medical home team. Prepare and maintain a case record for each patient to describe the nature of social problems and services suggested or provided, responsible for follow-up and case documentation.

Perform other duties as assigned.


The ideal candidate will possess the following qualifications:


  • Bachelor's Degree Social Work Required

  • Master's Degree Social Work Preferred


  • 3 years working in a Community/Outpatient setting, in the Geriatric field working in a Direct Service capacity, or Social Work experience in an Inpatient setting Required

  • Healthcare setting Preferred

  • Previous experience in Home Care setting a Plus

  • Chronic disease management of diverse patient populations and/or experience in health coaching Preferred

Licenses and Certifications

  • LCSW - Licensed Clinical Social Worker Upon Hire Required or

  • LBSW - Licensed Bachelor Social Worker Upon Hire Required or

  • LMSW - Licensed Master Social Worker Upon Hire Required and

  • DL – Valid Texas Driver’s License Required

Travel Requirements

  • 50% Local D/FW Metroplex


  • Must have knowledge and demonstrate knowledge of community information and resources for referrals.

  • Must work well with geriatric population with the ability to counsel and provide crisis intervene with patients and families, particularly regarding end of life issues.

  • Excellent time management skills with ability to prioritize tasks effectively.

  • Computer literate with software proficiency covering a wide variety of applications including word processing and spreadsheets (Microsoft Word, Excel, Access, PowerPoint, Outlook, EPIC, etc. programs) Strongly Preferred


Individual Contributor

ADA Requirements

Extreme Heat 1-33%

Extreme Cold 1-33%

Extreme Swings in Temperature 1-33%

Extreme Noise 1-33%

Working Outdoors 34-66%

Working Indoors 67% or more

Mechanical Hazards 1-33%

Electrical Hazards 1-33%

Explosive Hazards 1-33%

Fume/Odor Hazards 1-33%

Dust/Mites Hazards 1-33%

Chemical Hazards 1-33%

Toxic Waste Hazards 1-33%

Radiation Hazards 1-33%

Wet Hazards 1-33%

Heights 1-33%

Other Conditions 1-33%

Physical Demands


Employment opportunities are only reflective of wholly owned Texas Health Resources entities.

We are an Equal Opportunity Employer and do not discriminate against any employees or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.