$69,000-78,000 depending on years of experience Position Summary The Licensed Medical Social Worker provides psychosocial assessment, care coordination, and supportive counseling to patients and families in healthcare and community-based settings. This role supports individuals empaneled to the CHHA for skilled services (Nursing, Occupational Therapy, Physical Therapy and Speech Therapy) throughout Fulton and Montgomery counties. Patients reside in their homes or in an Assisted Living Facility/Program and are considered to be in a homebound status. Key Responsibilities Conduct comprehensive psychosocial assessments addressing medical, mental health, housing, and financial needs Must be done in person or via virtual platform; some follow up appointments may be done via phone call Develop and implement individualized care and discharge plans in collaboration with interdisciplinary healthcare team within the CHHA Provide crisis intervention, grief counseling, and emotional support to patients and families Coordinate referrals to local resources (e.g., DSS, mental health services, home care, transportation, substance use programs) Advocate for patient access to healthcare services, insurance benefits, and community supports Assist with safe discharge planning , including placement in rehab, skilled nursing, or home-based care Maintain accurate, timely clinical documentation in compliance with NYS regulations and agency policies Participate in case conferences, multidisciplinary rounds, and care coordination meetings Educate patients and families on treatment plans, resources, and long-term care options Minimum Qualifications Master's Degree in Social Work (MSW) Current unencumbered New York State LMSW License Completion of required NYS training—Child Abuse Mandated Reporter Course Ability to work with diverse and rural patient populations; Ability to work in diverse and rural home care settings Preferred Qualifications 2+ year experience in healthcare, hospital, or community-based setting Knowledge of local county systems (Medicaid, DSS, OMH services) Experience with discharge planning and care coordination Ability to work in a team setting and work toward mutual goals for the betterment of patients Bilingual (Spanish or other languages common in the region) Key Skills Strong communication and interdisciplinary collaboration Crisis management and problem-solving Knowledge of healthcare systems and community resources Cultural competence and ethical decision-making