Social Worker- NHTD/TBI
About The Position
The Social Worker provides specialized psychosocial support, care coordination, and oversight services to individuals with Traumatic Brain Injury (TBI) and other complex medical needs receiving home care and community-based services. This role is responsible not only for supporting client well-being and independence, but also for ensuring quality, consistency, and accountability in service delivery across the care team. Working closely with nurses, home health aides, and external providers, the Social Worker plays a critical role in monitoring care effectiveness, identifying performance concerns, and escalating issues to ensure safe, compliant, and outcome-driven care.
Requirements
- Master’s Degree in Social Work required
- Active New York State LMSW or LCSW required
- Must have experience in home care, managed care, or waiver programs (e.g., TBI, NHTD)
Nice To Haves
- Experience working with TBI, neurological conditions, or medically complex populations preferred
- Familiarity with Medicaid, DOH regulations, and waiver-based service models preferred
Responsibilities
- Conduct comprehensive psychosocial assessments for individuals with TBI and complex medical conditions
- Develop, implement, and update person-centered service plans in collaboration with clients, families, and interdisciplinary teams
- Provide ongoing care coordination across home care services, medical providers, and community-based programs
- Actively monitor service delivery to ensure alignment with care plans, client needs, and organizational standards
- Collaborate closely with nurses, home health aides, and external providers to ensure continuity of care, including proactive communication, real-time problem-solving, and alignment on client outcomes
- Identify, document, and escalate concerns related to care quality, staff performance, or client safety to appropriate clinical leadership
- Partner with supervisory nursing staff to support oversight and performance management of home health aides, including reinforcing expectations, reporting concerns, and contributing to corrective action processes
- Support clients in transitioning safely within the community, including hospital discharges and changes in level of care
- Assist with navigation of TBI waiver services, home care supports, and community resources
- Identify and address social determinants of health, including housing, financial stability, and access to care
- Advocate for clients to promote independence, safety, and community integration
- Monitor client progress and reassess needs to ensure services remain appropriate and effective
- Participate in incident reporting, quality assurance activities, and compliance-related initiatives as required
- Provide crisis intervention and psychosocial support as needed
- Maintain timely, accurate, and compliant documentation in accordance with DOH, Medicaid, and organizational standards
- Participate in interdisciplinary team meetings, case conferences, and program improvement initiatives
- Ensure adherence to HIPAA and all regulatory requirements
- Perform additional duties as assigned
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
