Social Worker

The PRN Social Worker provides social work interventions, case management, resource coordination, and emotional support to patients and families receiving home health services. This role works closely with nurses, therapists, physicians, and caregivers to assess needs, coordinate services, and ensure the patient's plan of care supports safety, well-being, and independence. This is an as-needed position supporting patient visits, assessments, follow-ups, and discharge planning.

Key Responsibilities

• Conduct initial and ongoing psychosocial assessments for patients receiving home health services.
• Identify emotional, social, financial, and environmental needs impacting the patient's health and safety.
• Provide counseling, crisis intervention, and short-term supportive therapy to patients and families.
• Educate patients and caregivers on coping strategies, adjustment to illness, and available community resources.
• Develop and implement patient-centered care plans addressing social determinants of health and service needs.
• Coordinate community resources such as Medicaid waivers, financial assistance, transportation, senior programs, durable medical equipment, meal services, and mental health referrals.
• Work collaboratively with the interdisciplinary team (IDT) to identify needs, update the plan of care, and ensure timely interventions.
• Provide coverage for patient visits, assessments, and urgent social work needs as requested.
• Assist with facility outreach, complex case management, and team communication when available.
• Support the clinical team during periods of high census, staff PTO, or unexpected needs.

Qualifications

• Master's Degree in Social Work (MSW) from an accredited program (preferred); Bachelor's in Social Work (BSW) considered with strong home health or medical social work experience.
• Current state Social Worker license (LMSW, LCSW, or equivalent).
• 1–2 years of case management experience in home health, hospice, hospital, or community health setting.
• Experience working with diverse populations and navigating community resources.
• Strong assessment, counseling, crisis intervention, and care coordination skills.
• Valid driver's license, reliable transportation, and ability to conduct home visits.
• Knowledge of Medicare/Medicaid regulations and community resource programs.
• Familiarity with EMR documentation systems ALORA Plus preferred.