Social Worker- NHTD/TBI
$70,000–$70,000 year
On-siteRochester, New York, United States
Job Summary
Conduct comprehensive psychosocial assessments and develop person-centered service plans for individuals with Traumatic Brain Injury and complex medical needs. Coordinate care across home health services, medical providers, and community programs while monitoring service delivery against care plans and organizational standards. Collaborate with nurses, home health aides, and external providers to ensure continuity of care, identify performance concerns, and escalate issues to clinical leadership. Support client transitions, navigate waiver services, and address social determinants of health including housing and financial stability. Provide crisis intervention, maintain compliant documentation, and participate in interdisciplinary team meetings and quality assurance initiatives.
Required Qualifications
- Master's Degree in Social Work
- Active New York State LMSW or LCSW
- Experience in home care, managed care, or waiver programs (e.g., TBI, NHTD)
- Strong understanding of home care operations, care coordination, and interdisciplinary team dynamics
- Demonstrated ability to identify issues, escalate concerns, and contribute to performance improvement efforts
- Ability to manage a caseload while maintaining high standards of care, compliance, and accountability
- Strong interpersonal, organizational, and problem-solving skills
- TBI-focused care and understanding of cognitive and behavioral impacts
- Care coordination with an emphasis on accountability and outcomes
- Strong clinical judgment and decision-making
- Ability to identify risks and escalate concerns appropriately
- Knowledge of home care operations and community-based service systems
- Professional communication and interdisciplinary collaboration
- Crisis intervention and problem-solving
- Documentation accuracy and regulatory compliance
- Accountability, ownership, and follow-through
- Relationship-building with clients, families, and care teams
- Adaptability in fast-paced, field-based environments
Desired Qualifications
- Experience working with TBI, neurological conditions, or medically complex populations
- Familiarity with Medicaid, DOH regulations, and waiver-based service models
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