Home Health Medical Social Worker

Center Well Home Health is seeking a PRN Home Health Medical Social Worker to provide compassionate, in-home psychosocial support to seniors and adults with chronic conditions. In this role, you will complete assessments, develop care plans, connect patients and families with community resources, and collaborate closely with our interdisciplinary team to promote safety, independence, and quality of life 'll document visits, participate in case conferences, and support transitions of care while working within a patient-first culture focused on respect, teamwork, and professional growth.

Responsibilities

• Provide psychosocial assessments for home health patients and families
• Develop and implement care plans addressing emotional and social needs
• Coordinate community resources, benefits, and support services
• Collaborate with nurses, therapists, and physicians on care planning
• Educate patients and caregivers on coping strategies and care options
• Advocate for patient rights, safety, and access to services
• Document visits, assessments, and interventions accurately and timely
• Participate in case conferences and interdisciplinary team meetings
• Support transitions of care and discharge planning
• Maintain compliance with regulatory and agency standards

Required Skills

• Psychosocial assessment
• Care planning
• Case management
• Knowledge of community resources
• Electronic health records (EHR) documentation
• Crisis intervention
• Patient and family counseling
• Interdisciplinary collaboration
• Discharge planning
• Regulatory and Medicare/Medicaid knowledge