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Advanced Illness Management - Medical Social Worker

Granite VNA

Current opening: Monday - Friday 8 a.m. - 4 p.m.

Reporting to the Clinical Director/Manager, the Advanced Illness Management (AIM) Medical Social Worker (MSW) delivers age appropriate care to the patient in the home setting currently under the care of home health with advanced stages of a serious illness, in order to bridge gaps between curative and comfort directed care. The AIM MSW works collaboratively with the AIM Coordinator, patients, care givers and other healthcare team members to ensure a smooth transition across all care settings by coordinating clinical care and services have been arranged to meet patient/family goals. The AIM MSW will provide education, in-services, and guidance on how patients can access their home care and hospice benefits. The AIM MSW will maintain all standards of professional practice.

Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Develops and implements appropriate plan of care (POC) that complies with referral source orders, specific treatment measures, frequency/expected duration and discharge goals in partnership with the patient, healthcare provider, patient representative (if any) and/or caregiver(s) based on thorough assessment incorporating all aspects of patient limitations and goals, and potential discharge environment
  • Documents accurate and ongoing assessment, treatment and discharge of the patient: interventions, patient response to care provided, patient needs, problems, capabilities, limitations and progress toward goals. Documentation includes evidence of appropriate patient/caregiver teaching, and the understanding of these instructions in accordance with agency timeframes.
  • Engages the patient /caregiver in meaningful education as indicated per care plan.
  • Facilitates conversations with patients and families regarding goals of care and assists with smooth transition to hospice when appropriate.
  • Maintains knowledge of the Medicare Conditions of Participation for Hospice.
  • Proactively identifies and works with members of the Palliative Care and Hospice interdisciplinary teams.
  • Coordinate and provide phone contact and/or informational visits with patients/families with identified needs after discharge from home care or hospice. Communicates with all physicians involved in the POC and other health practitioners related to the current POC.
  • Demonstrates responsibility to effectively coordinate the patient’s POC with members of the interdisciplinary team and other health professionals through family meetings and team/patient care conference. Updates patient’s short-term/long-term goals as
  • appropriate based on interdisciplinary team assessments and re-assessments.
  • Participates in interdisciplinary team, agency projects, committees, QAPI program and/or other activities upon request and approval from direct supervisor.
  • Attends Agency In-service programs.

Other Job Functions

  • Coach, mentor and precept new medical social work employees and students.
  1. Master's degree in social work from an accredited program (Council on Social Work Education)
  2. One to two years of social work experience in a Hospice/Palliative care setting.
How to Apply:

To apply, please visit our website directly at Thank you and we look forward to reviewing your application! 

Salary Range:

based on experience and education

Job Location:


Date Added: March 25, 2021

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