Home Health Medical Social Worker

CenterWell Home Health seeks a Home Health Medical Social Worker to provide compassionate in-home psychosocial support to seniors and adults with chronic conditions. You will complete assessments, develop care plans, provide counseling, and connect patients and families to community resources that promote safety, wellness, and independence at home. Working within an interdisciplinary team, you'll advocate for patient needs, support discharge planning, and maintain thorough documentation while contributing to a respectful, patient-first culture focused on quality care and professional growth.

Responsibilities

• Provide psychosocial assessments and counseling for home health patients and families
• Develop and implement individualized care plans in collaboration with the interdisciplinary team
• Coordinate community resources, benefits, and support services for patients
• Educate patients and caregivers on coping strategies, advance directives, and care options
• Advocate for patient needs to ensure safe discharge planning and continuity of care
• Document visits, assessments, and care plans in accordance with agency and regulatory standards
• Participate in case conferences and collaborate with nurses, therapists, and physicians
• Respond to urgent psychosocial needs and assist with crisis intervention in the home setting

Required Skills

• Psychosocial assessment
• Care planning
• Counseling and crisis intervention
• Knowledge of community resources
• Case management
• Home health regulations and compliance
• Electronic health record (EHR) documentation
• Interdisciplinary team collaboration
• Discharge planning
• Patient and family education