Social Worker
Core
Engage in dialogue to assess patient needs (physical, emotional, psychological, social), develop tailored care plans, set measurable goals, and provide ongoing support and resource navigation for patients transitioning from hospital to home.
Role type
Senior Social Worker (Home Health Care)
Builds
Integrated home health care services and community care models
Domain
Healthcare / Social Services
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 patient 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 patient assessments, develop and adjust care plans, provide ongoing guidance and support, coordinate with multidisciplinary teams, facilitate referrals to community resources, conduct follow-up visits (in-person or virtual)
Seniority
Senior, hands-on IC
