Job Description Summary

The Medical Social Worker (MSW), contracted or employed by the organization, provides psychosocial services in accordance with the Medicare Hospice Conditions of Participation (CoPs), Washington State regulations, and Heartlinks policies. The MSW is responsible for assessing psychosocial needs, implementing the plan of care, supporting patients and families through the end-of-life process, and collaborating with the interdisciplinary group (IDG) to ensure patient-centered, compliant, and compassionate care.

Essential Job Functions/Responsibilities:

• Conducts initial and ongoing comprehensive psychosocial assessments of patients and families/caregivers within required timeframes per Medicare CoPs and agency policy.
• Assesses emotional status, social support, financial concerns, living environment, cultural and spiritual needs, advance care planning, safety risks, and caregiving capacity.
• Communicates assessment findings to the Registered Nurse and other IDG members in a timely manner.
• Develops, implements, evaluates, and updates the individualized Plan of Care in collaboration with the IDG.
• Provides counseling, crisis intervention, and emotional support related to anticipatory grief, terminal illness, loss, family dynamics, and end-of-life decision-making.
• Educates patients and families on available community resources, benefits, legal planning, funeral planning, and advance directives.
• Serves as a liaison between patients/families, hospice staff, physicians, facilities, and community agencies to support continuity of care.
• Maintains accurate, complete, timely, and compliant clinical documentation in accordance with Medicare CoPs, Washington State regulations, and agency policy.
• Participates in Interdisciplinary Group (IDG) meetings at least every 15 days, contributing psychosocial updates and recommendations as required by CoPs.
• Participates in Quality Assessment and Performance Improvement (QAPI) activities.
• Assists the physician and clinical team in understanding significant social, emotional, environmental, and family factors impacting the patient’s care and disease progression.
• Identifies risk factors including abuse, neglect, exploitation, housing insecurity, caregiver burnout, and safety concerns, and reports per Washington State mandatory reporting laws.
• Maintains and develops professional relationships with public and private community agencies to support patient and staff needs.
• Provides bereavement support and appropriate referrals in coordination with the bereavement program, as assigned.
• Maintains patient confidentiality in compliance with HIPAA, Medicare CoPs, and Washington State privacy laws.
• Completes required training, in-services, competencies, and continuing education as required by regulation and agency policy.
• Assists with patient intakes, informational visits, and pre-admission consultations as assigned, including providing psychosocial screening, education regarding hospice or palliative care services, and coordination with clinical and admissions staff to support timely and appropriate patient admissions.
• Assists with staff, patient/family and facility educational needs as requested, including providing education on psychosocial aspects of illness, grief and bereavement, coping strategies, caregiver support, community resources, and hospice philosophy.
• Performs other duties as assigned by the Chief Care Experience Officer in support of patient care and regulatory compliance.

Caseload Expectations:

• Maintains an average caseload of approximately 30 hospice patients, with a maximum caseload of 35 patients based on patient acuity, geographic coverage, and organizational need.
• Caseload expectations may be adjusted by the CCEO or CEO to ensure safe, compliant, and high-quality patient care.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Position Qualifications:

• Bachelor’s Degree in Social Work(BSW) from a program accredited by the Council on Social Work Education (CSWE) required; Master’s Degree in Social Work (MSW) preferred.
• Minimum of one (1) year of experience in healthcare required; hospice or palliative care experience strongly preferred.
• Knowledge of hospice philosophy, terminal illness, grief, loss, bereavement, and end-of-life ethics.
• Current Washington State Social Worker license (LASW, LSWAIC, or LICSW), as applicable to role and scope of practice.
• Current CPR certification is required.
• Demonstrated ability to work independently, prioritize tasks, manage time efficiently, and function effectively within an interdisciplinary team.
• Strong verbal, written, and electronic documentation skills.
• Must possess a valid Washington State driver’s license, maintain a reliable insured vehicle, and meet organizational auto insurance requirements.

Physical & Environmental Requirements:

• Ability to travel by automobile through out assigned service area.
• Ability to sit, stand, walk, bend, and lift up to 25 pounds.
• Ability to work in patient homes, facilities, and community settings with varying environmental conditions.
• Emotional resilience and ability to work in end-of-life care environments.

Benefits:

• Full-time employees accrue up to 168 hours of PTO annually, in addition to accruing sick time at the rate of 1 hour for every 40 hours worked. Bereavement and jury duty leave are also available.
• Option to enroll in medical, dental, vision, and life insurance. Heartlinks pays for 100% of the employee's medical premium for the base plan and 75% of the employee's dental and vision premiums. Health benefits begin the first of the month after the start date.
• Miles driven for work are reimbursed.
• Holiday pay for 6 observed holidays.
• Ability to enroll in 401(k) and begin contributing at the time of hire. Heartlinks will match dollar for dollar up to 5% of earnings after one year of employment and 1080 hours worked.
• Tuition reimbursement/professional development assistance.
• Premium pay for hospice-related certifications.