Social Worker, Home Health NE Region
Core
Provide psychosocial support, assessment, and case management to patients and families coping with chronic, acute, or terminal illnesses in a home health setting.
Role type
Home Health Social Worker
Builds
Individualized plans of care and transition plans for patients and families
Domain
Healthcare / Home Health
Deliverable
client delivery
Required skills
psychosocial assessment, intervention planning, care coordination, counseling, advocacy, knowledge of payer networks, risk screening
Preferred skills
acute care experience, 2+ years social work experience
Technologies
electronic medical record systems
Responsibilities
Conduct bio-psycho-social assessments to create individualized plans of care; coordinate complex transition plans with patients, families, and community providers; advocate for patient rights and access to protective services; monitor patient progress and prevent readmissions using risk screening tools; collaborate with interdisciplinary teams to manage length of stay and facilitate timely referrals.
