Medical Social Worker, Palliative Care & Oncology

JOB SUMMARY

The Medical Social Worker provides comprehensive psychosocial assessment, counseling, care coordination, and advance care planning for patients with cancer and other advanced illnesses across outpatient oncology and community-based palliative care settings. This role addresses the emotional, social, environmental, and financial factors that impact patient outcomes, treatment adherence, and quality of life.

Working as part of an interdisciplinary team, the Medical Social Worker supports patients and caregivers from diagnosis through advanced illness and end-of-life, ensuring care is aligned with patient goals and is sustainable within the home and community setting.

Role Integration Summary:

This role integrates the episodic, treatment-focused demands of oncology with the longitudinal, home- and community-centered approach of palliative care. The Medical Social Worker must balance crisis intervention, care coordination, and sustained therapeutic engagement.

PRINCIPLE FUNTIONS include the following. Other duties may be assigned.

Provide Outpatient Psychosocial Evaluation for Advanced Illness Population

• Conducts comprehensive biopsychosocial assessments of patients and families, including evaluation of environment, age-specific needs, coping skills, spiritual resources, caregiver capacity, and financial/social stressors related to complex medical conditions
• Reviews medical records thoroughly and consults with collateral sources including providers, caregivers, and family members
• Interviews patients, families, and significant others to assess needs and identify barriers to care
• Collaborates with physicians, APPs (CRNPs), nursing, and interdisciplinary team members to identify behavioral health, cultural, family, and social concerns and their impact on the medical condition
• Assesses caregiver strengths and limitations, with focus on interventions to stabilize the home environment and support ongoing care
• Conducts home visits and supports outpatient and community-based palliative care services as appropriate
• Ensures all evaluations, referrals, and required documentation are completed thoroughly and in a timely manner

Develop and Implement Plan of Intervention

• Establishes therapeutic relationships with patients and families to support engagement in care
• Develops individualized care plans with short- and long-term goals aligned with the medical plan of treatment and patient values
• Provides ongoing counseling and therapeutic interventions to support coping, adjustment to illness, anticipatory grief, and mental health needs
• Utilizes evidence-based and goal-directed counseling techniques to assist patients and families in understanding diagnosis, prognosis, and treatment options
• Facilitates patient and family participation in healthcare decision-making, including goals-of-care discussions and advance care planning
• Apply problem-solving and clinical judgment to address barriers to care, including psychosocial, financial, and logistical challenges
• Conducts follow-up visits (clinic, home, or telehealth) as needed to reassess needs and adjust interventions
• Demonstrates understanding of oncology and palliative care treatment pathways and integrates this knowledge into care planning

Documentation in the Medical Record

• Completes timely, accurate, and thorough documentation of assessments, care plans, interventions, and outcomes in accordance with organizational policies
• Maintains clear and clinically relevant records that support continuity of care across settings
• Exercises sound clinical judgment in documentation, ensuring compliance with confidentiality, HIPAA, and release of information standards

Interdisciplinary and Community Communication

• Communicates psychosocial assessments, goals, and care plans effectively with interdisciplinary team members to support coordinated, patient-centered care
• Participate actively in team meetings, case reviews, and care planning discussions
• Serves as a liaison between patients, families, medical providers, and community agencies
• Maintains current knowledge of community resources and facilitates appropriate referrals (e.g., financial assistance, transportation, home care, hospice)
• Collaborates with community partners to ensure continuity of care and reduce gaps during care transitions

Advanced Complex Illness Population

• Demonstrates sensitivity and clinical skill in supporting patients and families facing serious and life-limiting illness
• Assists with aligning care decisions with patient goals, values, and medical realities
• Provides caregiver support, including assessment of burden, education, and resource connection
• Recognizes and addresses the impact of complex illness on family systems and functioning
• Adjusts schedule and availability as needed to meet patient and caregiver needs, including home-based and urgent situations
• Supports transitions across the continuum, including survivorship, chronic illness management, and end-of-life care

Professional Development and Accountability

• Maintains and advances clinical competency through ongoing education, supervision, and self-assessment
• Pursues continued learning in oncology, palliative care, and advanced illness management
• Maintains knowledge of healthcare regulations, including Medicare/Medicaid and eligibility for supportive services
• Stays informed of community resources and shares knowledge with team members
• Works toward or maintains advanced certification in palliative care social work (preferred)

JOB KNOWLEDGE & QUALIFICATIONS

Education

• Master’s Degree in Social Work (MSW) from a school of social work accredited by the Council of Social Work Education required.

Training and Experience

• Experience in oncology, palliative care and advanced illness care.

• Advanced care planning and goals of care discussions.
• Care transition and community-based resource coordination.
• Home-based or outpatient medical settings.
• Knowledge of Medicare/Medicaid, community resources, and legibility for supportive services.

Certificates, Licenses, Registrations

• License as required by Washington DOH to practice as a Social Worker:
  • LICSW (Licensed Independent Clinical Social Worker) required.                  
• Current American Heart Association BLS HCP required.
• Maintain a valid WA State Driver’s License. An out of state driver’s license will be acceptable in conjunction with a valid US Military ID.
• Current personal auto insurance and is insurable with the District’s insurance carrier.
• Washington State driving record upon hire and may be subject to annual driving record checks based on facility insurance carrier requirements.
• Certification in palliative care or oncology social work, preferred.