OverviewHarmonyCares is one of the nation's largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice. Our Mission – To bring personalized, quality-based healthcare to the home of patients who have difficult accessing care. Our Shared Vision – Every patient deserves access to quality healthcare. Our Values – The way we care is our legacy. Every interaction counts. Go the extra mile. Empower and support each other. Why You Should Want to Work with UsQuarterly Bonuses – up to $5000 per year!Health, Dental, Vision, Disability & Life Insurance, and much more401K Retirement Plan (with company match)Tuition, Professional License and Certification ReimbursementPaid Time Off, Holidays and Volunteer TimePaid Orientation and TrainingDay Time Hours (no holidays/weekends)Great Place to Work CertifiedEstablished in 11 statesLargest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today! More details about the benefits we offer can be found at https://careers.harmonycares.com/benefits. ResponsibilitiesThe Clinical Social Worker works collaboratively with the Care Team to provide care management services and helps address an individual's ability to maintain independence in the home, chronic care management, end of life decisions, cognitive/functional status, frequency acute care utilization, and a patient/caregiver support system. As a Clinical Social Worker you will:Manage a caseload of high risk socially complex patientsConduct face to face and telephonic psychosocial assessment with the patient and/or the caregiverInvestigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needsCoordinate services to ensure the patient/family understands a treatment planProvide outreach to community based services to support the patient's ability to age at homeDevelop and implement shared goals of care with the patient and familyProvide feedback to the home based primary care physician(HBPCP) to ensure he/she is aware of any early patient changesParticipate in Multidisciplinary Care Planning RoundsConduct additional psychosocial assessments as patient needs changeWork with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independenceOther duties/projects as assignedParticipates in quality improvement activities aimed to improve patient-population outcomes and associated processes. QualificationsRequired Knowledge, Skills and Experience Master's Degree in Social WorkCurrent unrestricted Social Work License or Limited License with preceptor or must be a licensed and boarded CSW or become licensed and boarded within 1-yearMust maintain a valid driver's license and good driving record3 years of experience in Care Management in community based setting or equivalentThe ability to use sound clinical judgment and communicate clearly in both written and verbal formatsAbove average computer skillsAbility to be self-directed and able to communicate effectively with professional staff across many disciplines and programsMust have the ability to plan time effectively, balance multiple tasks, work within stringent time frames, resolve problems, identify patient service trends, determine system improvements, and implement changeAbility to share expertise with others and demonstrates an understanding of the need to foster performance improvement while achieving patient satisfaction and efficiencyExperience with the homebound population, managed care, ACO, medical home or integrated case management environment is preferredPreferred Knowledge, Skills and Experience Experience working with the chronic, complex and/or behavioral health population Pay Transparency Individual compensation packages are based on various factors unique to each candidate, including skill set, experience, qualifications, and other job-related considerations. NoticeHarmonyCares and HarmonyCares Hospice are not affiliated with Harmony Hospice Care. HarmonyCares Hospice does not conduct business in OH. HarmonyCares Hospice conducts business in MI, VA, WI, TX, IN, IL.