Job Description

Medical Social Worker (MSW) -- Home Health

Department:

Clinical

Reports to:

Director of Patient Care Services / Administrator

Status:

Full-time or Per-Diem (Field)

Location:

Service across assigned counties (home visits)

Role Summary

The Home Health Medical Social Worker (MSW) delivers patient-centred psychosocial care in the home, supporting safe recovery, optimizing resources, and reducing avoidable readmissions. You will complete psychosocial assessments, provide brief counseling and crisis intervention, coordinate community resources, and collaborate closely with nursing and therapy to execute an effective plan of care.

Key Responsibilities

Conduct comprehensive

initial and ongoing psychosocial assessments

and develop an individualized

Social Work Plan of Care

aligned with patient goals and payer authorizations. Provide

brief counseling

, caregiver coaching,

crisis intervention

, adjustment-to-illness support, and

grief/ loss

education. Coordinate

community resources

(IHSS, transportation, meal programs, DME vendors, financial/insurance assistance, mental health, senior services) and facilitate referrals. Lead

discharge / transition planning

and barriers-to-care resolution (housing instability, safety concerns, caregiver strain). Educate patients/families on

advance care planning

(POLST/advance directives) and facilitate documentation when appropriate. Participate in

interdisciplinary case conferences

, communicate timely with RN Case Managers, PT/OT/ST, and physicians; update goals and visit frequencies as needs change. Complete accurate, timely documentation in the EMR (

WellSky/Kinnser

or equivalent) within agency turnaround standards (typically within 24 hours of visit). Adhere to all

Medicare Conditions of Participation

, state regulations (e.g., CA Title 22), payer requirements, and agency policies including

EVV

(electronic visit verification) and privacy/HIPAA. Identify and report

suspected abuse/neglect

per mandated-reporter laws; maintain professional boundaries and safety in the home setting. Support

quality improvement

(QAPI), respond to QA feedback, and meet productivity and patient-experience targets.
Qualifications

Master's degree in Social Work (MSW)

from a CSWE-accredited program.

Current California licensure

:

LCSW preferred

;

ASW

considered per payer policy and supervision requirements.

1+ year

recent experience in

home health, hospital, SNF, hospice, or community health

(home health strongly preferred). Working knowledge of

Medicare/Managed Care

home health coverage, community benefits, and care-transition best practices. Proficiency with EMR systems (e.g.,

WellSky/Kinnser

); strong documentation and time-management skills. Current

driver's license

, reliable insured vehicle, ability to travel between patient homes. Required clearances:

Background/OIG

,

TB/health screen

,

CPR

, vaccinations as applicable.

Bilingual (Spanish/English)

a plus.
Competencies

Empathic communication, cultural humility, de-escalation, and solution-focused counseling. Resourcefulness in complex psychosocial cases; sound clinical judgment and safety awareness in homes. Collaboration and accountability within an interdisciplinary team; professional, timely follow-through.
Physical / Environmental

Frequent driving; ability to sit/stand/walk; occasional lifting up to ~25 lbs; varied home environments.
Schedule & Travel

Flexible schedule based on patient needs; occasional late-day or weekend visits as authorized. Travel within assigned territory;

mileage reimbursement per agency policy

.
Performance Expectations (KPIs)

Documentation submitted

within 24 hours

of each visit. Attendance and contribution to

case conference/IDT

. Patient/caregiver satisfaction and timely closure of resource linkages. Compliance with EVV, safety, and regulatory standards.
Equal Opportunity

We are an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.

Pay: $80.00 - $90.00 per hour

Work Location: On the road