Medical Social Worker- Home Health

Make a meaningful difference where it matters most—at home. As a Medical Social Worker Home Health, you’ll play a vital role in supporting patients and their families through some of life’s most challenging moments. You’ll provide compassionate psychosocial care, education, and advocacy while collaborating closely with an interdisciplinary Clinical Care Management team to promote positive outcomes and smooth transitions across the healthcare continuum.

This role is ideal for a dedicated social work professional who thrives in a fast-paced, patient-centered environment and is passionate about holistic care.

Essential Functions

• Conduct comprehensive psychosocial assessments by interviewing patients and their social support systems

• Provide counseling, emotional support, education, and crisis intervention to patients and families coping with hospitalization, disability, chronic, or terminal illness
• Collaborate with patients, families, and the multidisciplinary care team to develop and implement individualized plans of care addressing identified psychosocial needs
• Serve as a resource to physicians and hospital staff regarding emotional, social, and psychosocial factors affecting patients and their support systems
• Participate actively in multidisciplinary care planning meetings and care transitions
• Assess patients and support systems for appropriate post-hospital level of care and environment across the continuum
• Maintain current knowledge of community agencies and resources; provide education and referrals for social, emotional, and financial assistance
• Report suspected cases of child and adult abuse, neglect, or exploitation and act as liaison with the Department of Social Services during investigations
• Identify and document clinical, psychosocial, and financial barriers to effective care transitions and assist in system improvement efforts
• Maintain accurate, timely documentation and case records in the medical record according to departmental standards
• Work collaboratively with Clinical Care Management leadership to identify challenges, recommend solutions, and support resolution

Education, Experience, Licensure & Certifications

• Master’s degree in Social Work from a program accredited by the Council on Social Work Education (required)
• Licensed Clinical Social Worker (LCSW) preferred
• Must meet and maintain state licensure requirements
• Minimum of 1 year of professional experience in a hospital or healthcare-related setting preferred
• Proficiency with data management and documentation tools
• Adherence to the National Association of Social Workers (NASW) Code of Ethics