Job Description

This full-time professional role that focuses on supporting individuals around care transitions by developing patient-centered care plans and addressing the social, emotional, and practical needs of patients and families navigating end-of-life decisions. With many patients facing limited care options, the social worker plays a vital role in facilitating difficult conversations about prognosis, helping families navigate unfamiliar healthcare systems, and honoring diverse cultural/belief systems. This role requires proactive, compassionate, and assertive communication, both within the interdisciplinary team and with patients, families, and community partners, especially in the context of discharge planning. Social workers must be able to set clear and respectful boundaries, quickly assess for safety and bereavement needs, and remain composed when interacting with complex family dynamics in a fast-paced, high-acuity environment. The schedule for this position is Monday-Friday 8:30am-5:00pm; every other weekend; holidays as assigned.

Responsibilities what you do

• Conduct comprehensive psychosocial assessments in accordance with regulatory and agency standards, identifying and proactively addressing evolving needs throughout the patient’s stay.
• Develop, coordinate, and implement individualized, holistic plans of care in collaboration with patients, their authorized representatives, and the interdisciplinary group (IDG).
• Provide emotional support and psychosocial interventions to enhance coping, strengthen family systems, and support patients and families through end-of-life care, including education on care options, hiring private caregivers, placement resources, levels of care and more.
• Independently provide regular updates on discharge planning progress and proactively escalate cases that may benefit from leadership input or present complex or safety related needs or concerns.
• Lead and coordinate timely discharge planning, ensuring clear communication of expectations and next steps with patients, families, and the care team, while proactively addressing logistical needs such as transportation, durable medical equipment (DME), and coordination with business offices, field staff, and external partners to support coordination of care.
• Assist patients and families in applying for Medicaid and accessing financial or community-based resources to support care needs.
• Complete accurate and timely documentation of all patient/significant other interactions, interventions, and updates to plan of care according to the standards of this agency.
• Actively participate in IDG meetings, offering psychosocial insights and educating team members on family systems theory, coping strategies, and other meaningful resources.
• Assist patients and families with funeral and final arrangements, facilitate discussions around advanced care planning, and advocate for patient rights and preferences throughout the care journey.
• Identify and communicate safety-related concerns to appropriate team members or departments, and support interventions that promote a safe and supportive care environment.
• Conduct ongoing bereavement risk assessments, including anticipatory grief support, evaluation of post-death safety concerns, and follow-up bereavement calls to key family members, ensuring a thoughtful and timely handoff to the bereavement department for continued support.
• Ensure timely and respectful communication with patients and families, maintaining confidentiality and verifying that information is shared only with authorized representatives, while involving the patient in care decisions to the greatest extent possible.
• Remain flexible and responsive to changing patient needs and staffing demands, including cross-coverage in the field or support with admissions when required by departmental or agency needs.
• Support performance improvement initiatives, ensure regulatory and licensure compliance, and uphold high ethical and professional standards in social work practice. Provide facility tours and patient/family education as needed.
• Perform other duties as assigned by supervisor.

Expectations how you do it

• Model professionalism and empathy by consistently demonstrating compassion, respect, teamwork, and dedication in all interactions with coworkers, customers, and partners.
• Adhere to all TL policies, procedures, and organizational guidelines, ensuring compliance in daily work and decision‑making.
• Deliver care and services in accordance with ACHC Standards and Medicare Conditions of Participation when applicable to your role.
• Comply with all relevant state and federal laws, regulations, and professional standards within your defined scope of responsibility.
• Promptly communicate concerns, issues, or potential risks to your immediate supervisor or another member of the management team to support a safe and effective work environment

Requirements what you need

• Master’s degree in Social Work (MSW) from an accredited university. (required)
• Minimum of 2 years’ experience in hospice or end-of-life care. (preferred)
• Licensed Clinical Social Worker (LCSW) credential (preferred)
• Working knowledge of Medicaid, Medicare regulations, placement processes, licensing laws, and accreditation standards.
• Strong commitment to diversity, equity, and inclusion (DEI) across the organization
• Proficient computer and documentation skills.
• Reliable transportation required for travel within the service area
• Ability to lift and/or carry items up to 25 pounds
• Sensory and communication abilities necessary to assess patients, interact with families and providers, and complete documentation.
• Must be able to travel to and function effectively in patient homes and facilities across the service area