Health at Home
Location
Port St. Lucie, Florida
The Medical Social Worker will conduct comprehensive psychosocial assessments to evaluate patient needs and develop individualized social work interventions based on the physician’s plan of care. This role involves providing counseling, coordinating community resources, supporting advance care planning, and ensuring continuity of care during transitions.
Candidates must possess a Master’s Degree in Social Work accredited by the Council on Social Work Education and hold a current Social Work license in the state(s) of practice. A minimum of one year of experience in a healthcare setting is required, with home health experience being preferred.
Medical Social Worker (MSW) – Home Health Health at Home | People Helping People
The Medical Social Worker at Health at Home plays a vital role in supporting patients and families through some of life’s most challenging moments. This position blends compassion, advocacy, and clinical expertise to help patients navigate social, emotional, and environmental barriers while receiving care in the comfort of their own homes.
Working as an integral part of our interdisciplinary team, the Medical Social Worker assesses needs, connects patients and caregivers to meaningful community resources, and provides counseling and education that promote safety, stability, and independence. This role also supports advance care planning, care transitions, and crisis intervention, ensuring patients feel heard, supported, and empowered throughout their home health journey.
At Health at Home, our Medical Social Workers do more than complete visits. They build trust, create impact, and help patients maintain dignity and quality of life while living where they feel most comfortable. This is a role for someone who believes healthcare should feel personal, supportive, and rooted in genuine human connection.
A. Completes comprehensive psychosocial assessments to evaluate social, emotional, environmental, and financial needs related to the patient’s condition and home situation.
B. Develops and implements individualized social work interventions based on assessment findings and the physician’s plan of care.
C. Provides counseling, education, and emotional support to patients and families to assist with adjustment to illness, disability, or life changes.
D. Serves as a liaison between patients, families, healthcare providers, and community agencies to coordinate services and resources.
E. Assists patients and caregivers with advance care planning, community referrals, financial resources, and long-term care planning as appropriate.
F. Participates actively in interdisciplinary team meetings, case conferences, and care planning discussions.
G. Supports discharge planning and care transitions to ensure continuity of care and patient safety.
H. Maintains accurate, timely, and compliant documentation in accordance with Medicare, state, and agency standards.
I. Communicates significant psychosocial findings and concerns to the Clinical Manager, Case Manager, and care team promptly.
J. Upholds Health at Home’s mission of People Helping People by delivering compassionate, ethical, and respectful care.
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