Job Summary:

Provides coordinated care in the home to patients/clients of all age groups and performs psychosocial assessments, analysis,
counseling, and referrals to meet the needs of the patient/client and family. Participates in the coordination of care.

Essential Duties:

• Performs ongoing clinical assessment of home health patients/clients to identify psychosocial, financial, environmental, and community resource needs as evidenced by the Plan of Care (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 healthcare practitioners 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 Agency’s QAPI program.
• Participates in the Agency sponsored in-service trainings.
• Provides supervision of social work assistants, if applicable.

Job Qualifications:

Education:

Master’s degree in social work from a Council on Social Work Education (CSWE) accredited social work program;
or doctoral degree in social work from an accredited university acceptable by the CSWE; or a baccalaureate
degree in social work from a CSWE accredited social work program and is supervised by a licensed medical social
worker (LMSW) and has one year of social work experience in a healthcare setting.

Licensure:

Current and valid license (LMSW) or (LBSW) as a social worker issued by the Texas Board of Social Worker
Examiners. Current driver’s license.

Experience:

One year of experience as a medical social worker in a healthcare setting.
Skills: Working knowledge of community resources. Good interpersonal skills. Proof of current CPR certification.