Social Worker, Patient​/Health Advocate

Transitions Care is seeking a compassionate Social Worker to support hospice patients and families across home and facility settings. In this role, you will complete psychosocial assessments, develop care plans, provide counseling, and connect families with community resources. You will collaborate closely with nurses, physicians, chaplains, and aides to address emotional, social, and practical needs, facilitate goals-of-care discussions, and support advance care planning.

You'll help families navigate grief, advocate for patient dignity, and ensure care aligns with values and preferences.

Responsibilities

• Conduct comprehensive psychosocial assessments for hospice patients and families
• Develop and implement individualized care plans in collaboration with the interdisciplinary team
• Provide counseling, emotional support, and crisis intervention to patients and caregivers
• Facilitate goals-of-care conversations and support advance care planning
• Connect patients and families with financial, legal, and community support resources
• Coordinate care across home, facility, and hospital settings to ensure continuity
• Support grief, loss, and bereavement needs during and after end of life
• Advocate for patient dignity, cultural preferences, and informed decision-making
• Maintain accurate, timely documentation in the electronic medical record
• Participate in interdisciplinary team meetings, case conferences, and quality initiatives

Required Skills

• Psychosocial assessment
• Care planning
• Crisis intervention
• Grief and bereavement counseling
• End-of-life care coordination
• Interdisciplinary team collaboration
• Community resource referral
• Patient and family education
• Documentation and EMR use
• Cultural competence in healthcare