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Medical Social Worker (MSW) – Home HealthHealth at Home | People Helping People

The Medical Social Worker at Health at Home plays a vital role in supporting patients and families through some of life’s most challenging moments. This position blends compassion, advocacy, and clinical expertise to help patients navigate social, emotional, and environmental barriers while receiving care in the comfort of their own homes.

Working as an integral part of our interdisciplinary team, the Medical Social Worker assesses needs, connects patients and caregivers to meaningful community resources, and provides counseling and education that promote safety, stability, and independence. This role also supports advance care planning, care transitions, and crisis intervention, ensuring patients feel heard, supported, and empowered throughout their home health journey.

At Health at Home, our Medical Social Workers do more than complete visits. They build trust, create impact, and help patients maintain dignity and quality of life while living where they feel most comfortable. This is a role for someone who believes healthcare should feel personal, supportive, and rooted in genuine human connection.

Essential Job Functions/Responsibilities:

A.    Completes comprehensive psychosocial assessments to evaluate social, emotional, environmental, and financial needs related to the patient’s condition and home situation.

B.    Develops and implements individualized social work interventions based on assessment findings and the physician’s plan of care.

C.    Provides counseling, education, and emotional support to patients and families to assist with adjustment to illness, disability, or life changes.

D.    Serves as a liaison between patients, families, healthcare providers, and community agencies to coordinate services and resources.

E.    Assists patients and caregivers with advance care planning, community referrals, financial resources, and long-term care planning as appropriate.

F.    Participates actively in interdisciplinary team meetings, case conferences, and care planning discussions.

G.   Supports discharge planning and care transitions to ensure continuity of care and patient safety.

H.    Maintains accurate, timely, and compliant documentation in accordance with Medicare, state, and agency standards.

I.      Communicates significant psychosocial findings and concerns to the Clinical Manager, Case Manager, and care team promptly.

J.     Upholds Health at Home’s mission of People Helping People by delivering compassionate, ethical, and respectful care.

Position Qualifications:

1. Graduate of a Master’s Degree program in Social Work accredited by the Council on Social Work Education.
2. Current Social Work license in the state(s) of practice, as required.
3. Minimum of one year of experience in a healthcare setting; home health experience preferred.
4. Demonstrates strong interpersonal, communication, and organizational skills.
5. Ability to work independently while collaborating effectively within an interdisciplinary team.
6. Current CPR certification is required.
7. Excellent communication, leadership, and organizational skills.