Home Health Medical Social Worker

About the role

Help patients overcome the social and emotional barriers that stand between illness and recovery. As a Home Health Medical Social Worker, you'll provide essential psychosocial support that empowers patients and families to follow their medical treatment plans, access community resources, and work toward independence and wellness. This role is perfect for a licensed MSW who wants to make a tangible impact on health outcomes by addressing the social determinants that affect recovery. You'll work collaboratively with nurses, therapists, and physicians to ensure patients have the emotional support, resources, and problem-solving tools they need to succeed at home.

Responsibilities

• Assess and Address Psychosocial Needs
• Complete initial social work evaluations within 5 days of start of care
• Assess social and emotional factors affecting patients' ability to follow medical recommendations
• Re-evaluate psychosocial needs during follow-up visits to track progress
• Help patients and families cope with problems in daily living that impact health
• Identify barriers to recovery and develop strategies to overcome them
• Counsel and Educate
• Provide counseling to facilitate adherence to medical treatment plans
• Teach and promote healthy lifestyles and psychosocial wellness
• Help patients understand how social and emotional factors impact their health
• Support families in understanding and implementing care plans
• Work toward patient and caregiver independence as the ultimate goal
• Connect Patients with Resources
• Identify and utilize community and family resources to support long-term plans
• Help patients learn to live within their disability or manage chronic conditions
• Address personal, financial, and environmental difficulties affecting health
• Provide information about community agencies and support services
• Coordinate resources that enable patients to remain safely in the community
• Collaborate on Care Planning
• Develop individualized social work care plans with case managers, physicians, patients, and families
• Set appropriate, measurable goals that address psychosocial barriers to health
• Participate in multidisciplinary care conferences for complex cases
• Initiate care conferences when needed to ensure coordination
• Contribute to discharge planning to support long-term success
• Help the healthcare team understand significance of social and emotional factors in recovery
• Maintain Clinical Excellence
• Complete accurate, timely documentation and weekly activity logs
• Maintain current knowledge of Medicare Conditions of Participation for social work services
• Participate in quality improvement initiatives
• Stay current with social work trends and evidence-based practices
• Ensure clinical notes reflect ongoing communication with team members

Requirements

• Required Qualifications
• Master's or doctoral degree from a CSWE-accredited school of social work
• Current State License as a Master's Social Worker (MSW/LMSW/LCSW)
• Minimum 1 year of experience as a licensed Master's Social Worker
• Reliable transportation with valid automobile insurance
• Willingness to travel daily for home visits within service area
• Previous home health or medical social work experience
• Knowledge of Medicare home health benefit and Conditions of Participation
• Experience with care coordination and discharge planning
• Essential Skills and Competencies
• Strong clinical assessment and counseling skills
• Ability to identify and address social determinants of health
• Knowledge of community resources and social service systems
• Excellent communication and patient education abilities
• Skill in navigating complex family dynamics and emotio

Benefits

Additional Information

Optimal Care is where your dedication meets a rewarding career. As a clinician owned and operated company, we create the opportunity and environment for each employee to realize their highest potential while maintaining a personalized focus on our Patients and Families every day. We are the Midwest's premier provider of Physician Services, Home Health, and Hospice Care. Our integrated care delivery model incorporates technology, innovation and best practices. We produce value based outcomes by managing chronic disease process, rehabilitation and end of life care. We live a simple Mission: Serve Together, Provide Value, and Deliver Exceptional Quality Care. What does this mean for you? At Optimal Care, you have our resolute commitment to being an exceptional place to work. Your expertise, passion and commitment to exceptional quality care will continue to thrive. With you we can build a remarkable place to work. Exceptional Benefits: Minimum of 3 Weeks Paid Time Off (PTO) Company Vehicle Program for field roles Medical, Dental, and Vision Insurance HSA and FSA options including Dependent Care Company paid Short Term Disability Company paid Life Insurance 401(k) with Employer Match Mileage Reimbursement Pet Insurance ID and Fraud Protection And more...

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