Medical Social Worker - Home Health

**Home Health Medical Social Worker (MSW)** **Heartland Healthcare Inc. – Portland Metro Area, Oregon** **About Heartland Healthcare** Heartland Healthcare is a Medicare\-certified home health agency committed to providing compassionate, patient\-centered care in the comfort of our patients’ homes. Our interdisciplinary team works together to address each patient’s medical, emotional, and social needs, helping them achieve the highest possible quality of life while remaining safely at home. We are currently seeking a compassionate and dedicated **Medical Social Worker (MSW)** to join our growing home health team. **Position Summary** The Home Health Medical Social Worker provides skilled social work services to patients and their families to address psychosocial, emotional, financial, and environmental factors that may affect health, recovery, and independence. The Medical Social Worker collaborates with physicians, nurses, rehabilitation therapists, and community agencies to develop individualized care plans and connect patients with appropriate community resources. **Responsibilities** * Perform comprehensive psychosocial assessments of patients and their support systems. * Identify social, emotional, financial, cultural, and environmental barriers that may impact recovery. * Develop individualized plans of care in collaboration with the interdisciplinary team. * Provide counseling and emotional support to patients and caregivers coping with illness, disability, or end\-of\-life issues. * Assist patients and families with advance care planning, community resources, financial assistance programs, transportation, housing, caregiver support, and long\-term care planning. * Coordinate referrals to community agencies and social service organizations. * Assist with discharge planning and transitions of care to promote safe and effective outcomes. * Educate patients and caregivers regarding available healthcare and community resources. * Participate in interdisci