Home Health Medical Social Worker

Optimal Care is growing and proactively building our talent pipeline for future opportunities. While this role may not be immediately available, we invite you to submit your resume to this posting. A member of our Recruiting team will reach out to discuss opportunities with you. Optimal C are is where your dedication meets a rewarding career.  Top Work Places for 12 consecutive years, Great Places to Work certified for 6 consecutive years, and we believe that exceptional care starts with exceptional people. We’re committed to supporting your professional growth, valuing your expertise, and creating an environment where you can do your best work every day. As a clinician-owned and operated organization, we empower our team members to provide personalized, compassionate care to patients and families every day. We are a leading provider of Physician Services, Home Health, and Hospice that encourages collaboration, innovation, and clinical excellence. From chronic disease management and rehabilitation to end-of-life care, our focus is on improving outcomes and enhancing quality of life. We live a simple Mission:  Serve Together, Provide Value, and Deliver Exceptional Quality Care. About the Role Help patients overcome the social and emotional barriers that stand between illness and recovery. As a Home Health Medical Social Worker, you'll provide essential psychosocial support that empowers patients and families to follow their medical treatment plans, access community resources, and work toward independence and wellness.  This role is perfect for a licensed MSW who wants to make a tangible impact on health outcomes by addressing the social determinants that affect recovery. You'll work collaboratively with nurses, therapists, and physicians to ensure patients have the emotional support, resources, and problem-solving tools they need to succeed at home. What You'll Do Assess and Address Psychosocial Needs Complete initial social work evaluations within 5 days of start of care Assess social and emotional factors affecting patients' ability to follow medical recommendations Re-evaluate psychosocial needs during follow-up visits to track progress Help patients and families cope with problems in daily living that impact health Identify barriers to recovery and develop strategies to overcome them Counsel and Educate Provide counseling to facilitate adherence to medical treatment plans Teach and promote healthy lifestyles and psychosocial wellness Help patients understand how social and emotional factors impact their health Support families in understanding and implementing care plans Work toward patient and caregiver independence as the ultimate goal Connect Patients with Resources Identify and utilize community and family resources to support long-term plans Help patients learn to live within their disability or manage chronic conditions Address personal, financial, and environmental difficulties affecting health Provide information about community agencies and support services Coordinate resources that enable patients to remain safely in the community Collaborate on Care Planning Develop individualized social work care plans with case managers, physicians, patients, and families Set appropriate, measurable goals that address psychosocial barriers to health Participate in multidisciplinary care conferences for complex cases Initiate care conferences when needed to ensure coordination Contribute to discharge planning to support long-term success Help the healthcare team understand significance of social and emotional factors in recovery Maintain Clinical Excellence Complete accurate, timely documentation and weekly activity logs Maintain current knowledge of Medicare Conditions of Participation for social work services Participate in quality improvement initiatives Stay current with social work trends and evidence-based practices Ensure clinical notes reflect ongoing communication with team members What We're Looking For Required Qualifications Master's or doctoral degree from a CSWE-accredited school of social work Current State License as a Master's Social Worker (MSW/LMSW/LCSW) Minimum 1 year of experience as a licensed Master's Social Worker Reliable transportation with valid automobile insurance Willingness to travel daily for home visits within service area Preferred Qualifications Previous home health or medical social work experience Knowledge of Medicare home health benefit and Conditions of Participation Experience with care coordination and discharge planning Essential Skills and Competencies Strong clinical assessment and counseling skills Ability to identify and address social determinants of health Knowledge of community resources and social service systems Excellent communication and patient education abilities Skill in navigating complex family dynamics and emotional stress Cultural sensitivity and tolerance for diverse lifestyles Strong time management and organizational skills Ability to work independently while collaborating with multidisciplinary teams Understanding of how psychosocial factors impact medical recovery What Makes You Successful You're a resourceful problem-solver who understands that recovery isn't just about following doctor's orders - it's about addressing the financial, environmental, and emotional challenges that can derail even the best treatment plan. You know how to connect patients with the right resources at the right time.  You're an effective counselor who can help patients and families work through the emotional stress of illness while staying focused on practical solutions. You understand that your role is to empower patients toward independence, not create ongoing dependence on services.  You're a skilled collaborator who can translate complex social and emotional issues