Medical Social Worker — Home Health, PRN

Medical Social Worker — Home Health, PRN

Charity Comfort Care Services, LLC

Location: Dallas–Fort Worth and surrounding communities

Schedule: PRN/as needed with flexible scheduling

Reports to: Director of Nursing/Clinical Manager

Position Summary

Charity Comfort Care Services is seeking a compassionate, dependableTexas-licensed social worker to provide medical social work services to patients in their homes. The social worker will help patients and families address emotional, social, financial, and environmental challenges affecting recovery, safety, and access to care.

This position offers flexible scheduling based on patient needs, ordered visit frequencies, and accepted assignments. Home visits, timely documentation inAxxess Home Health, and participation in care coordination conference calls are essential responsibilities.

Required Qualifications

• Master’s or doctoral degree in social work from a program accredited by the Council on Social Work Education.
• Current, active TexasLMSW or LCSW license, in good standing. All services must remain within the employee’s authorized scope of practice, with appropriate supervision when required.
• At leastone year of social work experience in a healthcare setting.
• Working knowledge ofAxxess Home Health, including reviewing patient charts, managing assigned visits, documenting assessments and interventions, and communicating with the care team.
• Understanding of home health care planning, patient rights, confidentiality, HIPAA, mandated reporting, and applicable Texas and federal requirements.
• Strong assessment, communication, organization, and problem-solving skills.
• Ability to work independently in the field while collaborating with the agency’s interdisciplinary team.
• Reliable transportation; valid driver’s license and automobile insurance when driving for work.
• Access to a secure, compatible device and reliable internet for electronic documentation and conference calls.
• Successful completion of applicable background checks, exclusion screenings, credential verification, and agency onboarding requirements.
• Ability to perform essential job functions, with or without reasonable accommodation.

Essential Job Duties

Patient Assessment and Care Planning

• Complete initial and follow-up psychosocial assessments as ordered and assigned.
• Evaluate support systems, caregiver availability, coping skills, financial concerns, housing stability, and barriers to following the plan of care.
• Identify social and environmental factors that affect the patient’s health, recovery, and ability to remain safely at home.
• Develop measurable social work goals, interventions, and visit recommendations in collaboration with the patient, caregiver, and care team.
• Reassess progress and recommend changes to services when patient needs change.

Patient and Family Support

• Provide supportive counseling and education related to illness, disability, adjustment, grief, caregiver stress, and healthcare decisions within the social worker’s licensed scope.
• Help patients and families understand available services and navigate applications and referral processes.
• Connect patients with transportation, food assistance, benefits counseling, housing resources, caregiver support, and other community services.
• Assist with advance care planning resources and referrals as appropriate.
• Support discharge planning and transitions between home, hospital, rehabilitation, and other care settings.
• Recognize and promptly report suspected abuse, neglect, exploitation, and urgent safety concerns according to law and agency policy.

Axxess Documentation and Communication

• Review referral information, orders, relevant clinical notes, and the current plan of care before visits.
• Maintain accurate visit schedules and promptly communicate missed visits, cancellations, and scheduling concerns.
• Document assessments, services provided, patient responses, referrals, progress toward goals, and discharge recommendations in Axxess within agency deadlines.
• Complete and authenticate assigned documentation accurately; respond promptly to documentation corrections.
• Communicate significant findings and changes to the Director of Nursing/Clinical Manager and other appropriate team members.
• Protect patient information when using electronic records, mobile devices, email, and virtual meetings.

Conference Calls and Team Participation

• Participate in scheduled interdisciplinary case conferences, care coordination calls, staff meetings, and required training.
• Provide concise updates on patient progress, caregiver concerns, resource referrals, barriers, and discharge needs.
• Collaborate with nursing, therapy, physicians or other ordering practitioners, case managers, and community partners.
• Attend remotely when permitted and coordinate availability with the agency.

Professional Responsibilities

• Follow the authorized plan of care, payer requirements, agency policies, and professional ethical standards.
• Maintain current licensure, required continuing education, and agency competencies.
• Participate in quality improvement, chart reviews, and survey readiness activities as assigned.
• Provide respectful, culturally responsive care to patients and families of diverse backgrounds.

Preferred Qualifications

• Previous home health experience.
• Experience serving older adults, veterans, people with disabilities, and patients with complex medical or social needs.
• Familiarity with Dallas–Fort Worth community resources, Medicaid services, Medicare, and VA support programs.
• Bilingual communication skills.

PRN Schedule

Visits are assigned according to referrals, patient needs, service area, and clinician availability. Scheduling is flexible, but accepted assignments must meet ordered timeframes, documentation deadlines, and care coordination requirements.PRN hours and visit volume are not guaranteed.