Home Health Medical Social Worker

Performs ongoing clinical assessment of home health patients/clients to identify psychosocial, financial, environmental and community resource needs as evidenced by the POC, documentation, clinical records, case conferences and community resource referrals. Develops and evaluates the plan of care in partnership with the patient/client, representative (if any), and caregiver(s).

Accepts clinical assignments that are consistent with education and competence to meet the needs of the patients/clients. Provides services that are ordered by the physician as indicated in the plan of care, including patient/client, caregiver and family counseling and patient/client and caregiver education. Prepares clinical notes.

Uses effective interpersonal relations and communication skills; facilitates the use of these skills by other team members to achieve desirable outcomes. Communicates with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care. Meets mandatory continuing education requirements of the Agency and licensing board.

Demonstrates commitment, professional growth and competency by maintaining a working knowledge of public and private eligibility standards and requirements. Promotes the Agency philosophy and administrative policies to ensure quality of care. Collaborates with the interdisciplinary team to promote coordination of patient/client care.

Participates in the Agency’s QAPI program. Participates in Agency-sponsored in-service training.