Medical Social Worker - Home Health - Per Diem​/Req

Job Objective

The Medical Social Worker provides support, active listening and counseling, resource identification, and assistance for home health patients.

• Assesses the social and emotional factors related to the patient’s illness and required care.
• Demonstrates understanding of the relationship between medical and nursing needs and the patient’s home situation, financial resources, and available community resources.
• Takes appropriate action to obtain available community resources to assist in the resolution of patients problems.
• Acts as the patient advocate, protects patient confidentiality, and provides counseling on services required by patient.
• Demonstrates knowledge regarding special needs and behaviors of age specific groups and demonstrates proficiency in required age specific competencies.
• Demonstrates understanding of patient’s insurance coverage for social services.
• Maintains own schedule for patient visits and communicates visit plans with Director of Patient Care Services and/or Case Manager.

• Able to communicate effectively while maintaining good working relationships with co‑workers, managers and office staff.
• Acts as a resource for patients to ensure understanding and compliance of the assessment plan.
• Participates in interdisciplinary case conferences, in‑service programs, and committee meetings.
• Communicates to Case Manager, physicians and/or Director of Patient Care Services changes in the patient condition and needs.

• Prepares complete, concise and clear documentation of planned interventions, patient’s response to treatment, changes in patient condition and coordination with other services.
• All documentation is completed timely within agency policies.
• Effective oral and written communication skills for reporting and recording clinical findings.

• Participates in age specific educational and training programs.

• Participates in Quality Improvement (QAPI) process as requested in Utilization Review (UR), chart audits, and PI committees.
• Participates in orientation of other department Medical Social Worker’s.
• Other duties as assigned.

• Thorough knowledge of the Practice of Social Worker including assessment of patient’s social needs, counseling services, and community resources.
• Thorough knowledge of agency’s policies, procedures and practices.

• Caring bedside manner: demonstrates ability to provide services with compassion and caring.
• Effective oral and written communication skills with Case Managers/Director of Patient Care Services (DPCS) and patient/caregivers, as appropriate.
• Strong assessment skills.
• Strong critical thinking skills.
• Basic computer skills required.

• Organization – must demonstrate basic ability to maintain schedule of home visits and complete paperwork according to agency procedures.
• Must have good communication skills and have the ability to connect with patients and families in their homes in a kind and compassionate way.
• Ability to project and maintain professionalism in all aspects of patient’s care.
• Ability to function independently seeking assistance when appropriate.
• Ability to take ownership of patient’s plan of care including establishing an appropriate plan of care, overseeing that care is done according to plan of care, communicate with physician and revise plan of care as needed.
• Ability to understand basic Home Health regulations and financial impact of care being provided.
• Ability to oversee that all aspects of the patient’s care meet all regulations, and that payment is authorized as required.

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our…