Medical Social Worker - PRN Home Health

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. 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 into terms that medical professionals understand, helping the entire team see patients holistically. You work comfortably in diverse home environments, adapting your approach to meet families where they are - literally and figuratively. Why Join Us? Home health medical social work offers the opportunity to see direct connections between your interventions and patient outcomes. When you help a patient access transportation to therapy appointments, secure medical equipment, or navigate insurance challenges, you're removing real barriers to recovery. We provide comprehensive orientation to home health social work, ongoing supervision and support, and opportunities for professional development. You'll work with a collaborative multidisciplinary team that values your expertise in addressing the psychosocial factors essential to successful home care. Professional Growth Opportunities: Training on Medicare home health regulations and documentation Education on care coordination and discharge planning Interdisciplinary collaboration skills Work Environment and Schedule This position requires daily travel to patient homes and residential facilities within your service area, with occasional office meetings. You'll work independently during home visits while staying connected to your care team through regular communication and care conferences. Schedule flexibility is important as you'll need to adapt to patient needs, new referrals, and changing conditions. Most visits occur during standard business hours, with occasional adjustments based on patient and family availability. Location Office Location: 770 Kenmoor Ave, Suite 100, Grand Rapids, MI 49546 Main Service Area: Grand Rapids, MI Hours Office Hours: 8:00 am – 5:00 pm, Monday through Friday How We Care for You Minimum of 3 Weeks Paid Time Off (PTO) Medical, Dental, and Vision Insurance HSA and FSA options including Dependent Care Company paid Short Term Disability 401(k) with Employer Match Mileage Reimbursement Company Vehicle Program for field roles Pet Insurance ID and Fraud Protection And more... Employment is contingent upon the successful completion of a background check. Screening is completed by a third‑party administrator, the Michigan Long‑Term Care Partnership, and is performed in compliance with the Fair Credit Report Act. Reasonable Accommodations We offer reasonable accommodations throughout the application process, interview stages, and during employment to ensure all team members can thrive. Please reach out to us if you would like to request a reasonable accommodation. Equal Opportunity Employer We believe an exceptional place to work begins with diverse perspectives. We are proud to be an equal‑opportunity workplace that prohibits discrimination and harassment of any kind based on race, color, religion, sex, national origin, age, disability, or any other protected characteristic. #J-18808-Ljbffr