Provides services and/or establishes standards addressing the social and/or emotional factors that impact the patient’s ability to achieve the goals of the Plan of Care. Services are provided under the direction of a physician and in conjunction with other health care team members in accordance with the established policies and practices of the Agency.  

• Master’s Degree from a school of Social Work accredited by the Council on Social Work Education. 
• Current and approved Hands-On CPR certification 
• Minimum of one (1) year of social work experience in a health care setting; home care experience preferred. 
• Demonstrates strong knowledge of resources available in the community. 
• Reliable transportation and demonstrated good driving record. 
• Demonstrates organizational and leadership ability. 
• Demonstrates a working knowledge of Medicare guidelines for home health coverage and compliance. 
• Must have good verbal and written communication skills and evaluation techniques and demonstrate knowledge of clinical skills, judgment, current nursing practices and analytical capabilities. 
• Must be familiar with Medicare, Medicaid, and other third-party payer guidelines. 
• Must have a current/valid driver’s license, agency-required automobile liability insurance, and availability of personal, dependable transportation to conduct home visits. 
• Able to assess patient status and identify requirements relative to age specific needs. 

Major Tasks, Duties, and Responsibilities

1. Attend clinical case conference meetings and meetings assigned by the Director of Nursing, Clinical Supervisor and/or Administrator. 
2. Appropriately refer to other disciples or community resources as needed. 
3. Complete safety and needs assessments accurately and identify actual or potential problems and solutions to patient problems. 
4. Maintain a working knowledge of available outreach programs. 
5. Respects confidentiality of information in the client clinical record and only shares this information in accordance with Agency policy and HIPAA 
6. Educate patients and families on services and interventions. 
7. Responsible for ensuring that the standards of clinical practice are being followed at all times. 
8. Responsible to report weekly schedule and report if over/under productivity. 
9. Acts in a professional manner, work as scheduled and report to work on time. 
10. Works with the Clinical Supervisor and Director of Nursing to ensure that Medicare guidelines and revisions are being followed. 
11. Follow procedures to work within the frame of the law and scope of practice. 
12. Record the coordination of care from the field staff into a patient’s chart. 
13. Report any problems of patients to the Physician and Clinical Supervisor. 
14. Communicate visits with the Clinical Supervisor to establish proper care of the patients. 
15. Prepares social histories to augment existing service, or as a guide in determining or changing level of service. This may include cultural factors, financial concerns and support system 
16. Ensure that all documentation is completed in a timely fashion. 
17. Keeps the Clinical Supervisor, Director of Nursing or Administrator apprised of any problems or potential problems. 
18. Provide in medical social work to homebound patients without prejudice. 
19. Ensure that all documentation is completed in a timely manner within the agency. 
20. Meet with the nurses, therapists, home health aides and other disciplines involved in the patient care for case conference on a weekly basis. 
21. Takes and writes physician orders as necessary and appropriate. 
22. Establishes and maintains an ongoing relationship with the physicians and their office staff, facilities, or other members of the community involved to promote continuity of care. 
23. Respects confidentiality of information in the client clinical record and only shares this information in accordance with Agency policy and HIPAA 
24. Represent the Agency at all times in a professional and loyal manner. 
25. Attend meetings, luncheons and in-services as needed. 
26. Communicate well verbally and in writing. 
27. Have excellent planning, time management and organizational skills 
28. Promote patient and community relations 
29. Participates in the development of the plan of care 
30. Participates in discharge planning and in-service programs 
31. Acts as a consultant to other agency personnel 
32. May perform other duties as assigned.