Optimal Care is where your dedication meets a rewarding career.

As a clinician owned and operated company, we create the opportunity and environment for each employee to realize their highest potential while maintaining a personalized focus on our Patients and Families every day. We are the Midwest's premier provider of Physician Services, Home Health, and Hospice Care. Our integrated care delivery model incorporates technology, innovation and best practices. We produce value based outcomes by managing chronic disease process, rehabilitation and end of life care.

We live a simple Mission: Serve Together, Provide Value, and Deliver Exceptional Quality Care.

What does this mean for you? At Optimal Care, you have our resolute commitment to being an exceptional place to work. Your expertise, passion and commitment to exceptional quality care will continue to thrive. With you we can build a remarkable place to work.

Exceptional Benefits:

Minimum of 3 Weeks Paid Time Off (PTO)
Company Vehicle Program for field roles
Medical, Dental, and Vision Insurance
HSA and FSA options including Dependent Care
Company paid Short Term Disability
Company paid Life Insurance
401(k) with Employer Match
Mileage Reimbursement
Pet Insurance
ID and Fraud Protection
And more...

About the Role

Help patients overcome the social and emotional barriers that stand between illness and recovery. As a Home Health Medical Social Worker, you'll provide essential psychosocial support that empowers patients and families to follow their medical treatment plans, access community resources, and work toward independence and wellness. This role is perfect for a licensed MSW who wants to make a tangible impact on health outcomes by addressing the social determinants that affect recovery. You'll work collaboratively with nurses, therapists, and physicians to ensure patients have the emotional support, resources, and problem-solving tools they need to succeed at home.

What You'll Do

Assess and Address Psychosocial Needs

Complete initial social work evaluations within 5 days of start of care
Assess social and emotional factors affecting patients' ability to follow medical recommendations
Re-evaluate psychosocial needs during follow-up visits to track progress
Help patients and families cope with problems in daily living that impact health
Identify barriers to recovery and develop strategies to overcome them

Counsel and Educate

Provide counseling to facilitate adherence to medical treatment plans
Teach and promote healthy lifestyles and psychosocial wellness
Help patients understand how social and emotional factors impact their health
Support families in understanding and implementing care plans
Work toward patient and caregiver independence as the ultimate goal

Connect Patients with Resources

Identify and utilize community and family resources to support long-term plans
Help patients learn to live within their disability or manage chronic conditions
Address personal, financial, and environmental difficulties affecting health
Provide information about community agencies and support services
Coordinate resources that enable patients to remain safely in the community

Collaborate on Care Planning

Develop individualized social work care plans with case managers, physicians, patients, and families
Set appropriate, measurable goals that address psychosocial barriers to health
Participate in multidisciplinary care conferences for complex cases
Initiate care conferences when needed to ensure coordination
Contribute to discharge planning to support long-term success
Help the healthcare team understand significance of social and emotional factors in recovery

Maintain Clinical Excellence

Complete accurate, timely documentation and weekly activity logs
Maintain current knowledge of Medicare Conditions of Participation for social work services
Participate in quality improvement initiatives
Stay current with social work trends and evidence-based practices
Ensure clinical notes reflect ongoing communication with team members

What We're Looking For

Required Qualifications

Master's or doctoral degree from a CSWE-accredited school of social work
Current State License as a Master's Social Worker (MSW/LMSW/LCSW)
Minimum 1 year of experience as a licensed Master's Social Worker
Reliable transportation with valid automobile insurance
Willingness to travel daily for home visits within service area

Preferred Qualifications

Previous home health or medical social work experience
Knowledge of Medicare home health benefit and Conditions of Participation
Experience with care coordination and discharge planning

Essential Skills and Competencies

Strong clinical assessment and counseling skills
Ability to identify and address social determinants of health
Knowledge of community resources and social service systems
Excellent communication and patient education abilities
Skill in navigating complex family dynamics and emotional stress
Cultural sensitivity and tolerance for diverse lifestyles
Strong time management and organizational skills
Ability to work independently while collaborating with multidisciplinary teams
Understanding of how psychosocial factors impact medical recovery

What Makes You Successful

You're a resourceful problem-solver who understands that recovery isn't just about following doctor's orders - it's about addressing the financial, environmental, and emotional challenges that can derail even the best treatment plan. You know how to connect patients with the right resources at the right time. You're an effective counselor who can help patients and families work through the emotional stress of illness while staying focused on practical solutions. You understand that your role is to empower patients toward independence, not create ongoing dependence on services. You're a skilled collaborator who can translate complex social and emotional issues into terms that medical professionals understand, helping the entire team see patients holistically. You work comfortably in diverse home environments, adapting your approach to meet families where they are - literally and figuratively.

Why Join Us?

Home health medical social work offers the opportunity to see direct connections between your interventions and patient outcomes. When you help a patient access transportation to therapy appointments, secure medical equipment, or navigate insurance challenges, you're removing real barriers to recovery. We provide comprehensive orientation to home health social work, ongoing supervision and support, and opportunities for professional development. You'll work with a collaborative multidisciplinary team that values your expertise in addressing the psychosocial factors essential to successful home care.

Professional Growth Opportunities:

Training on Medicare home health regulations and documentation
Education on care coordination and discharge planning
Community resource development
Interdisciplinary collaboration skills

Work Environment and Schedule

This position requires daily travel to patient homes and residential facilities within your service area, with occasional office meetings. You'll work independently during home visits while staying connected to your care team through regular communication and care conferences. Schedule flexibility is important as you'll need to adapt to patient needs, new referrals, and changing conditions. Most visits occur during standard business hours, with occasional adjustments based on patient and family availability.

Ready to Remove Barriers to Recovery?

If you're a licensed clinical social worker who wants to make a measurable impact on health outcomes by addressing the social and emotional factors that affect recovery, we'd love to hear from you.

Location

Office Location: 770 Kenmoor Ave, Suite 100, Grand Rapids, MI 49546 
Main Service Area: Grand Rapids, MI

Hours

Office Hours: 8:00 am – 5:00 pm, Monday through Friday

Home Health Medical Social Worker