Social Worker (Beaver Dam)

Assess psychosocial needs and apply interventions to support health treatment plans, enhancing patient and family functioning while facilitating access to services. Collaborate and coordinate care by developing patient goals, monitoring progress, addressing barriers, and evaluating outcomes of individualized care plans. Provide training, guidance, and mentorship to home health colleagues on managing complex psychosocial issues. Participate in discharge planning for transitions to skilled nursing, assisted living, outpatient dialysis, acute rehab, hospice, and transportation needs. Engage patients and families in decision-making regarding rights, confidentiality, and self-determination. Demonstrate sensitivity to cultural diversity and spiritual backgrounds while adhering to State and Federal regulations. Work schedules are determined by patient care needs, with potential weekend and holiday coverage.