Social Worker
Core
Provides psychosocial support, assessment, and case management to patients and families coping with chronic, acute, or terminal illnesses in a home care setting.
Role type
Home Care Social Worker
Builds
Individualized plans of care and transition plans for patients and families
Domain
Healthcare / Home Care
Required skills
psychosocial assessment, intervention planning, care coordination, counseling, advocacy, case management, interdisciplinary collaboration, risk screening
Preferred skills
acute care experience, 2+ years social work experience
Technologies
electronic medical record systems
Responsibilities
Conduct bio-psycho-social assessments and develop individualized plans of care; Provide counseling and support to patients and families; Coordinate complex transition plans with healthcare teams and community providers; Advocate for patient rights and access to protective services; Monitor patient progress and document in electronic medical records; Identify high-risk patients through screening and referrals.
Seniority
Mid-level, hands-on IC
