Medical Social Worker; MSW Fee for Service; Home Care

The Medical Social Worker (MSW) provides short-term, resource-focused social work services to home care patients in their place of residence. This role is strictly non-therapeutic and focuses on assessing psychosocial needs, facilitating access to community resources, and supporting safe care transitions. Services are provided on a fee-for-service basis and require travel to patient homes.

Job Description

The Medical Social Worker (MSW) provides short-term, resource-focused social work services to home care patients in their place of residence. This role is strictly non-therapeutic and focuses on assessing psychosocial needs, facilitating access to community resources, and supporting safe care transitions. Services are provided on a fee-for-service basis and require travel to patient homes.

• Conduct in-home psychosocial assessments to identify social, financial, environmental, and community support needs
• Educate patients and caregivers on available community resources and benefits
• Assist with referrals to community agencies (e.g., housing assistance, transportation, financial aid, food programs, long-term planning resources)
• Support care coordination and discharge planning in collaboration with the interdisciplinary care team
• Provide guidance related to advance directives, healthcare proxies, and long-term care planning (as appropriate)
• Document visits accurately and timely in accordance with agency policy and regulatory requirements
• Communicate findings and recommendations to clinical management and care team members

• This position does NOT include psychotherapy, counseling, or ongoing therapy services
• Services are short-term, goal-oriented, and resource-based only