Job Summary:
Provides coordinated care in the home to patients/clients of all age groups and perform psychosocial assessments, analysis, counseling and referrals to meet the needs of the patient/client and family. Participates in the coordination of care.
Job Classification: Clinical
Lines of Authority: Reports to the Supervising Nurse

Essential Functions

• Performs ongoing clinical assessment of home health patients/clients to identify psychosocial, financial, environmental and community resource needs as evidenced by the POC, documentation, clinical records, case conferences and community resource referrals.
• Develops and evaluates the plan of care in partnership with the patient/client, representative (if any), and caregiver(s).
• Accepts clinical assignments that are consistent with education and competence to meet the needs of the patients/clients.
• Provides services that are ordered by the physician as indicated in the plan of care, including patient/client, caregiver and family counseling and patient/client and caregiver education. Prepares clinical notes.
• Uses effective interpersonal relations and communication skills; facilitates the use of these skills by other team members to achieve desirable outcomes.
• Communicates with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care.
• Meets mandatory continuing education requirements of the Agency and licensing board.
• Demonstrates commitment, professional growth and competency by maintaining a working knowledge of public and private eligibility standards and requirements.
• Promotes the Agency philosophy and administrative policies to ensure quality of care.
• Collaborates with the interdisciplinary team to promote coordination of patient/client care.
• Participates in the Agencys QAPI program.
• Participates in Agency-sponsored in-service training.

Job Qualifications:
Education: Masters or Doctoral Degree from an accredited school of Social Work.
Licensure: Certification; Current drivers license.
Experience: One (1) year experience as a MSW in a health care setting.
Skills: Working knowledge of community resources. Good interpersonal skills. Proof of current CPR.
Transportation: Reliable transportation. Valid and current auto liability insurance.
Environmental and Working Conditions:
Works in patients/clients homes in various conditions. Occasional exposure to infectious diseases; ability to travel locally; some exposure to unpleasant weather.
Physical and Mental Effort:
Prolonged standing, walking and sitting required; requires working under some stressful conditions to meet deadlines and patient/client and family needs; and to make quick decisions and resource acquisition; meet patient/client and family psychosocial needs.