Responsibilities 

• Attend clinical case conference meetings and meetings assigned by the Director of Nursing, ADON, and/or Administrator.
• Appropriately refer to other disciplines or community resources as needed.
• Complete safety and needs assessments accurately and identify actual or potential problems and solutions to patient problems.
• Maintain a working knowledge of available outreach programs.
• Respects confidentiality of information in the client clinical record and only shares this information in accordance with Agency policy and HIPAA
• Educate patients and families on services and interventions.
• Responsible for ensuring that the standards of clinical practice are being followed at all times.
• Responsible to report weekly schedule and report if over/under productivity.
• Acts in a professional manner, work as scheduled and report to work on time.
• Works with the ADON and Director of Nursing to ensure that Medicare guidelines and revisions are being followed.
• Follow procedures to work within the frame of the law and scope of practice.
• Record the coordination of care from the field staff into a patient’s chart.
• Report any problems of patients to the Physician and Clinical Supervisor.
• Communicate visits with the Clinical Supervisor to establish proper care of the patients.
• 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
• Ensure that all documentation is completed in a timely fashion.
• Keeps the ADON, Director of Nursing or Administrator apprised of any problems or potential problems.
• Provide in medical social work to homebound patients without prejudice.
• Ensure that all documentation is completed in a timely manner within the agency.
• Meet with the nurses, therapists, home health aides and other disciplines involved in the patient care for case conference on a weekly basis. Attends a minimum of 1 team case conference per week.
• Takes and writes physician orders as necessary and appropriate.
• 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.
• Respects confidentiality of information in the client clinical record and only shares this information in accordance with Agency policy and HIPAA
• Represent the Agency at all times in a professional and loyal manner.
• Attend meetings, luncheons and in-services as needed.
• Communicate well verbally and in writing.
• Have excellent planning, time management and organizational skills
• Promote patient and community relations
• Participates in the development of the plan of care
• Participates in discharge planning and in-service programs
• Acts as a consultant to other agency personnel
• Assist with CEMP

Qualifications 

• Masters Degree from a school of Social Work accredited by the Council on Social Work Education
• Current and approved CPR certification
• Minimum of one (1) years’ experience in a health care setting or equivalent experience; 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.