Community-Connect Home Care LLC Medical Social Worker Bloomington, MN · Part time Company website

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CCHC is a direct Home and Community Based Service (HCBS) provider advocating Community Integration & support for people with Intellectual/Neurodevelopmental disabilities, mental health challenges and the elderly. We tailor care to your needs, whether in your home, family residence, or our community residential settings.

Position Summary 

The Medical Social Worker (MSW) supports patients and families by addressing psychosocial, emotional, financial, and environmental factors that impact overall health. The MSW conducts assessments, coordinates resources, advocates for client needs, and collaborates with the clinical team to promote well-being and continuity of care within the home care environment. 

It is anticipated that the services of MSW will improve compliance and customer satisfaction, grow our census, and facilitate the process of our company becoming a Medicare certified home health service and guide strategic business development. 

Key Responsibilities 

1. Patient Assessment & Care Planning 

- Conduct comprehensive psychosocial assessments. 

- Identify emotional, financial, environmental, and social concerns. 

- Develop individualized care plans aligned with client needs. 

- Update care plans based on follow-up and clinical changes. 

2. Counseling & Support Services 

- Provide emotional counseling, grief support, and crisis intervention. 

- Educate clients and families on coping strategies. 

- Assist clients facing chronic illness, disability, or life transitions. 

3. Resource Coordination & Advocacy 

- Connect clients with community resources such as housing, food programs, transportation, financial support, and mental health services. 

- Advocate for client rights and ensure access to appropriate care. 

- Assist with county, state, and federal program applications (e.g., MA, disability). 

4. Interdisciplinary Collaboration 

- Collaborate with nurses, caregivers, case managers, and leadership. 

- Participate in care conferences and interdisciplinary planning. 

- Communicate changes in client conditions or needs promptly. 

5. Care Transitions & Discharge Planning 

- Assist in transitioning clients from hospitals or facilities to home care. 

- Provide guidance on long-term care options and community programs. 

- Ensure clients and families understand service plans and the next steps. 

6. Documentation & Compliance 

- Document assessments, care plans, and interventions accurately in Alora or designated EHR systems. 

- Maintain compliance with state regulations, DHS requirements, HIPAA, and agency standards. 

7. Program Development & Quality Improvement 

- Support agency quality improvement initiatives. 

- Identify gaps in service delivery and recommend improvements. 

- Participate in staff training, community outreach, and resource development. 

Qualifications 

Education & Experience: 

- Master’s degree in Social Work (MSW) preferred. 

- Minnesota licensure: LGSW, LISW, or LICSW preferred. 

- Two+ years of home care, medical social work, or healthcare experience preferred. 

Skills & Competencies: 

-A good knowledge of Home Care Law and the working of the DHS and MDH 

-Participate actively in our application for grants 

- Strong assessment and crisis intervention skills. 

- Knowledge of Minnesota community resources and social service systems. 

- Excellent communication, documentation, and teamwork skills. 

- Ability to work independently in home care settings. 

- Cultural sensitivity and experience with diverse populations. 

- Experience with Alora or other EHR systems is a plus. 

Working Conditions 

- Field-based role requiring travel to client homes and community locations. 

- Flexible scheduling depending on client needs. 

- Exposure to emotional and sensitive situations. 

Essential Attributes 

- Compassionate and empathetic demeanor. 

- Strong ethical standards and professionalism. 

- Advocacy-focused approach to client care. 

- Excellent problem-solving and decision-making.