Home Health Social Worker (MSW)

Adaptive Home Health•Austin, TX

3d•$100,000 - $130,000•Remote

About The Position

Adaptive Home Health is building a higher-acuity, patient-centered home health model across Texas. Our Medical Social Workers play a critical role in addressing the psychosocial barriers that impact patient recovery and quality of life. We support our field clinicians with technology and operations designed to reduce administrative burden. Our charting product streamlines documentation, and our scheduling product (launching soon) will improve visit coordination and protect clinician time. If you are passionate about addressing social determinants of health and helping patients navigate complex systems, this role offers meaningful impact with strong operational support.

Requirements

Master's or doctoral degree from a CSWE-accredited school of social work
Texas LMSW or LCSW license (or state licensure if required by state law)
Minimum 1 year of social work experience in a healthcare setting (home health, hospice, hospital, or community health preferred)
CPR certification (BLS)
Valid Texas driver's license, auto insurance, and reliable transportation
Strong knowledge of community resources including housing, financial assistance programs, mental health services, and legal/funeral planning
Excellent oral and written communication and interpersonal skills
Ability to organize tasks, set priorities, and function effectively in high-autonomy field-based work
Flexibility with work hours and ability to travel locally
Fluency in English (written and spoken)

Nice To Haves

Previous home health or hospice social work experience
Familiarity with Homecare Homebase (HCHB) or similar EMR
Experience with discharge planning and care transitions
Bilingual (Spanish preferred in Texas markets)

Responsibilities

Conduct comprehensive psychosocial assessments to identify patient and family needs related to illness, recovery, and adjustment to care.
Evaluate the relationship between medical/nursing needs and available resources in the home setting, including financial, community, and caregiver support.
Connect patients and families with community resources to address barriers such as housing, transportation, financial assistance, medication programs, legal services, and funeral/memorial planning.
Provide counseling and education to patients and families on coping with emotional and social challenges related to illness and treatment.
Collaborate with physicians and interdisciplinary team members to communicate significant psychosocial factors affecting patient health and treatment adherence.
Participate in development and ongoing evaluation of the physician's Plan of Care, ensuring social and emotional needs are addressed.
Monitor and report changes in patient condition, psychosocial status, and response to interventions to the Clinical Manager and care team.
Participate in discharge planning to ensure continuity of care and successful transitions.
Serve as a resource to the interdisciplinary team for identifying and resolving patient psychosocial needs.
Supervise, instruct, and evaluate Social Work Assistants (BSW) when applicable, ensuring services are provided in compliance with company, government, and professional standards.
Maintain accurate and timely documentation including case conferences, patient/physician contacts, visit reports, progress notes, and coordination with other disciplines.