Home Health Medical Social Worker

Optimal Care - Evergreen•Jackson, MI

6d•$70,000 - $75,000•Hybrid

About The Position

Optimal Care is growing and proactively building our talent pipeline for future opportunities. While this role may not be immediately available, we invite you to submit your resume to this posting. A member of our Recruiting team will reach out to discuss opportunities with you. Optimal Care is where your dedication meets a rewarding career. Top Work Places for 12 consecutive years, Great Places to Work certified for 6 consecutive years, and we believe that exceptional care starts with exceptional people. We’re committed to supporting your professional growth, valuing your expertise, and creating an environment where you can do your best work every day. As a clinician-owned and operated organization, we empower our team members to provide personalized, compassionate care to patients and families every day. We are a leading provider of Physician Services, Home Health, and Hospice that encourages collaboration, innovation, and clinical excellence. From chronic disease management and rehabilitation to end-of-life care, our focus is on improving outcomes and enhancing quality of life. We live a simple Mission: Serve Together, Provide Value, and Deliver Exceptional Quality Care. Help patients overcome the social and emotional barriers that stand between illness and recovery. As a Home Health Medical Social Worker, you'll provide essential psychosocial support that empowers patients and families to follow their medical treatment plans, access community resources, and work toward independence and wellness. This role is perfect for a licensed MSW who wants to make a tangible impact on health outcomes by addressing the social determinants that affect recovery. You'll work collaboratively with nurses, therapists, and physicians to ensure patients have the emotional support, resources, and problem-solving tools they need to succeed at home.

Requirements

Master's or doctoral degree from a CSWE-accredited school of social work
Current State License as a Master's Social Worker (MSW/LMSW/LCSW)
Minimum 1 year of experience as a licensed Master's Social Worker
Reliable transportation with valid automobile insurance
Willingness to travel daily for home visits within service area
Strong clinical assessment and counseling skills
Ability to identify and address social determinants of health
Knowledge of community resources and social service systems
Excellent communication and patient education abilities
Skill in navigating complex family dynamics and emotional stress
Cultural sensitivity and tolerance for diverse lifestyles
Strong time management and organizational skills
Ability to work independently while collaborating with multidisciplinary teams
Understanding of how psychosocial factors impact medical recovery

Nice To Haves

Previous home health or medical social work experience
Knowledge of Medicare home health benefit and Conditions of Participation
Experience with care coordination and discharge planning

Responsibilities

Complete initial social work evaluations within 5 days of start of care
Assess social and emotional factors affecting patients' ability to follow medical recommendations
Re-evaluate psychosocial needs during follow-up visits to track progress
Help patients and families cope with problems in daily living that impact health
Identify barriers to recovery and develop strategies to overcome them
Provide counseling to facilitate adherence to medical treatment plans
Teach and promote healthy lifestyles and psychosocial wellness
Help patients understand how social and emotional factors impact their health
Support families in understanding and implementing care plans
Work toward patient and caregiver independence as the ultimate goal
Identify and utilize community and family resources to support long-term plans
Help patients learn to live within their disability or manage chronic conditions
Address personal, financial, and environmental difficulties affecting health
Provide information about community agencies and support services
Coordinate resources that enable patients to remain safely in the community
Develop individualized social work care plans with case managers, physicians, patients, and families
Set appropriate, measurable goals that address psychosocial barriers to health
Participate in multidisciplinary care conferences for complex cases
Initiate care conferences when needed to ensure coordination
Contribute to discharge planning to support long-term success
Help the healthcare team understand significance of social and emotional factors in recovery
Complete accurate, timely documentation and weekly activity logs
Maintain current knowledge of Medicare Conditions of Participation for social work services
Participate in quality improvement initiatives
Stay current with social work trends and evidence-based practices
Ensure clinical notes reflect ongoing communication with team members