Social Worker
Core
Engage in meaningful dialogue with patients to assess needs, develop tailored care plans, and provide ongoing support to help them navigate challenges and achieve goals.
Role type
Senior Social Worker (Home Health Care)
Builds
Integrated community care model for patient transitions from hospital to home
Domain
Healthcare / Home Health Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Client-centered care planning, multidisciplinary collaboration, community resource navigation, goal setting and progress tracking, virtual communication, diverse population management
Preferred skills
Master of Social Work, community setting experience, frail seniors care, multiple comorbidities management
Technologies
Microsoft Office, Microsoft Teams, Zoom, Go To Meeting
Responsibilities
Conduct comprehensive assessments of client needs, develop and adjust care plans, provide ongoing guidance and support, coordinate with multidisciplinary teams, facilitate referrals to community resources, conduct follow-up visits
Seniority
Senior, hands-on IC
