A Medical Social Worker provides social work services to patients on an intermittent basis in their place of residence.  This is performed in accordance with physician orders and plan of care under the direction and supervision of the Clinical Manager/Clinical Supervisor.


1. Master or Doctoral degree from a school of Social Work accredited by the Council on
Social Work Education.  

2. Minimum of one (1) year experience in health care, home health experience preferred.   

3. Current CPR certification and valid driver’s license.

4. Acceptance of philosophy and goals of the Agency.

5. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; social worker skills per competency checklist.


    1.The Medical Social Worker assumes responsibility for, but is not restricted to:

    1. Ongoing interdisciplinary assessment of the patient
    2. Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s)
    3. Providing services that are ordered by the physician as indicated in the plan of care
    4. Patient, caregiver, and family counseling
    5. Patient and caregiver education
    6. Preparing clinical notes
    7. Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care
    8. Participation in the Agency’s QAPI program
    9. Participation in agency-directed in-service training
  1. Assesses and evaluates patient’s status by:
    1. Writing and initiating plan of care
    2. Regularly re-evaluating patient and family/caregiver needs
    3. Participating in revising the plan of care as necessary
  2. Initiates the plan of care and makes necessary revisions as patient status and needs change.
  3. Develops a care plan that establishes goals, based on diagnoses and incorporates medical social work actions.  Includes the patient and the family in the planning process.
  4. Initiates social work program and instructs other personnel and/or family/caregiver in certain phases of the program with which they may work with a patient, as well as instructing them as to the goals of the social work program for the patient.
  5. Implements current medical social work practice following the plan of care.
  6. Provides accurate and timely documentation of patient services to reflect the plan of care.
  7. Provide patient and family/caregiver education and information pertinent to diagnosis and plan of care.
  8. Identifies patient and family/caregiver needs for other home health services and refers
    as necessary.
  9. Prepares and submits clinical and progress summaries based on the attainment of goals.
  10. Participates in coordination of Agency services, appropriately reporting the identified needs to the care team. 
  11. Uses equipment and supplies effectively.
  12. Evaluates and documents patient’s response to treatments/interventions.
  13. Participates in personal, professional growth and development.


The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job.  The incumbents may be requested to perform job-related tasks other than those stated in this description.



1.Supervised by: Clinical Manager/Supervisor or Master of Social Work, as


2.Employees Supervised: None

RISK EXPOSURE Moderate risk