The Medical Social Worker participates in the interdisciplinary care provided to home health patients. The Medical Social Worker functions to evaluate and develop a plan of care personalized to fit the patient’s emotional and social needs. The Medical Social Worker provides direction and supervision of the Social Worker Assistant as required and when involved in the patient’s plan of care. The Medical Social Worker works within CenterWell Home Health’s company-specific policy and procedures, applicable healthcare standards, governmental laws, and regulations. 

• Assesses the patient’s social and emotional state as it relates to his or her illness or injury, needs for care and his or her response to such treatment, and adjustments to care.
• Assesses any relationships of the patient’s medical and nursing needs in the home setting, financial resources, and available community resources.
• Provides any appropriate action to obtain available community resources to assist in resolving issues that may be impeding the patient’s recovery.
• Instructs patients and families in treating and coping with social and emotional response connected with Provides ongoing assessment of patient and family needs and responses to teaching
• Assists the physician and other health team members in understanding the significant social and emotional factors related to the patient’s health Participates in the development and periodic re-evaluation of the physician's Plan of Care for the patient.
• Observes, records, and reports changes in patients’ condition and response to treatment to the Clinical Manager and the Participates in the discharge planning process
• Participates as a member of the interdisciplinary care team in care coordination activities and acts as a resource to other health team members in the identification and resolution of patient needs
• Supervises instructs and evaluates the performance of the Social Work Assistant (BSW) to assure that all medical social services are provided to patients in compliance with Company, government, and professional standards
• Maintains and submits documentation as required by the company and/ or facility including any case conferences, patient/physician community contacts, visit reports progress notes, and confers with other health care disciplines in providing optimum patient.

Required Skills/Experience

• Masters or doctoral degree from a school of social work accredited by the Council on Social Work Education.
• Social Worker licensure in the state of practice; if required by state law or regulation.
• A valid driver’s license, auto insurance, and reliable transportation are required.
• Proof of current CPR certification
• Minimum of one year of experience as a social worker in a health care setting, home health, and/or hospice.
• Knowledge of and the ability to assist with discharge planning needs, and to obtain community resources (housing, shelter, funeral/memorial service arrangements, legal, information and referral, state/federal financial and medication programs, and eligibility.
• Excellent oral and written communication and interpersonal skills.
• Must read, write and speak fluent English.
• Knowledge of medications and their correct administration.
• Ability to organize tasks, develop action plans, set priorities, and function under stressful situations.
• Ability to be flexible in work hours and travel locally.
• Ability to communicate effectively with patients and their family members and at all levels of the organization.
• Maintains current licensure certifications and meets mandatory continuing education requirements.
• Must read, write and speak fluent English.
• Must have good and regular attendance.
• Performs other related duties as assigned.
• Valid driver’s license, auto insurance and reliable transportation.