Social Worker

About the Role:

We are seeking a compassionate and dedicated Social Worker to join our multidisciplinary healthcare team, working with seniors with chronic illnesses. This role is critical in improving the quality of life for our patients, helping them manage their conditions more effectively at home, and minimizing avoidable hospitalizations. The ideal candidate will have experience in end-of-life care, chronic illness management, and addressing social determinants of health.

As a Social Worker, you will play an integral role in supporting seniors during hospital visits, helping to facilitate goals of care conversations, coordinating discharge planning with hospital case managers, and assisting with advance care planning discussions. This is an excellent opportunity to make a meaningful impact on the lives of individuals and their families in a collaborative, team-oriented environment. You may also be required to make home visits, as well as offer services virtually, depending on patient needs.

Key Responsibilities:

• Visit patients in hospitals to support goals of care discussions, discharge planning, and coordination with hospital case managers.
• Facilitate advance care planning conversations with patients and families, ensuring that their wishes are respected and understood.
• Provide emotional support to patients and families dealing with terminal illness, chronic conditions, and end-of-life challenges.
• Address social determinants of health by connecting patients with community resources and services to improve their overall well-being and quality of life.
• Help develop and implement care plans to manage chronic illness, reduce hospital readmissions, and increase patient independence at home.
• Collaborate closely with physicians, nurses, and other healthcare team members to ensure coordinated, patient-centered care.
• Serve as a resource for family members, guiding them through difficult decisions and providing psychosocial support.
• Monitor and assess patient progress, adjusting care plans as needed to meet changing needs and improve outcomes.
• Conduct home visits as needed to assess patient needs and provide in-person support. ? Provide virtual services to patients when in-person visits are not necessary or feasible.

Qualifications:

• Required: Master’s degree in Social Work (MSW) and at least an LMSW (Licensed Master Social Worker) license.
• Preferred: LCSW (Licensed Clinical Social Worker).
• Bilingual in English and Spanish is preferred, with the ability to effectively communicate with diverse patient populations.
• Experience working with seniors and individuals with chronic illness is highly preferred. ? Experience in hospice, home health, or hospital settings is highly desirable. ? Familiarity with electronic health records (EHR) systems is preferred.
• Strong understanding of social determinants of health and experience connecting patients to resources.
• Excellent communication and interpersonal skills, with the ability to work effectively with patients, families, and a multi-disciplinary healthcare team.
• Ability to work independently and manage multiple priorities in a fast-paced environment. ? Compassionate and empathetic approach to patient care, with a deep understanding of end-of-life issues and emotional support needs.
• Must have reliable transportation to visit patients in their homes and attend hospital visits as needed. Mileage will be reimbursed.

Compensation & Benefits:

• Salary range: $75,000 - $92,000 annually, depending on experience.
• Comprehensive benefits package including medical, dental, and vision coverage.
• Paid time off (PTO), sick leave, and holidays.
• Continuing education and professional development opportunities.
• 401(k) retirement plan with employer contributions.

How to Apply:

Interested candidates should submit a resume and cover letter outlining their qualifications and experience. We are an equal opportunity employer and encourage individuals from all backgrounds to apply.

This role is a unique opportunity for a skilled Social Worker to join a supportive team in making a meaningful difference in the lives of seniors with chronic illness. If you’re passionate about improving quality of life and delivering compassionate care, we encourage you to apply!

Salary : $75,000 - $92,000