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Title: Social Worker- TBI & Home Care Services
Reports To: Director of TBI
Supervises:
Salary: $70,000 Annually
JOB SUMMARY:
The Social Worker provides specialized psychosocial support, care coordination, and oversight services to individuals with Traumatic Brain Injury (TBI) and other complex medical needs receiving home care and community-based services. This role is responsible not only for supporting client well-being and independence, but also for ensuring quality, consistency, and accountability in service delivery across the care team.
Working closely with nurses, home health aides, and external providers, the Social Worker plays a critical role in monitoring care effectiveness, identifying performance concerns, and escalating issues to ensure safe, compliant, and outcome-driven care.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Conduct comprehensive psychosocial assessments for individuals with TBI and complex medical conditions
• Develop, implement, and update person-centered service plans in collaboration with clients, families, and interdisciplinary teams
• Provide ongoing care coordination across home care services, medical providers, and community-based programs
• Actively monitor service delivery to ensure alignment with care plans, client needs, and organizational standards
• Collaborate closely with nurses, home health aides, and external providers to ensure continuity of care, including proactive communication, real-time problem-solving, and alignment on client outcomes
• Identify, document, and escalate concerns related to care quality, staff performance, or client safety to appropriate clinical leadership
• Partner with supervisory nursing staff to support oversight and performance management of home health aides, including reinforcing expectations, reporting concerns, and contributing to corrective action processes
• Support clients in transitioning safely within the community, including hospital discharges and changes in level of care
• Assist with navigation of TBI waiver services, home care supports, and community resources
• Identify and address social determinants of health, including housing, financial stability, and access to care
• Advocate for clients to promote independence, safety, and community integration
• Monitor client progress and reassess needs to ensure services remain appropriate and effective
• Participate in incident reporting, quality assurance activities, and compliance-related initiatives as required
• Provide crisis intervention and psychosocial support as needed
• Maintain timely, accurate, and compliant documentation in accordance with DOH, Medicaid, and organizational standards
• Participate in interdisciplinary team meetings, case conferences, and program improvement initiatives
• Ensure adherence to HIPAA and all regulatory requirements
• Perform additional duties as assigned
QUALIFICATIONS/EDUCATION/LICENSURE/CERTIFICATIONS:
• Master's Degree in Social Work required
• Active New York State LMSW or LCSW required
• Must have experience in home care, managed care, or waiver programs (e.g., TBI, NHTD)
• Experience working with TBI, neurological conditions, or medically complex populations preferred
• Strong understanding of home care operations, care coordination, and interdisciplinary team dynamics
• Familiarity with Medicaid, DOH regulations, and waiver-based service models preferred
• Demonstrated ability to identify issues, escalate concerns, and contribute to performance improvement efforts
• Ability to manage a caseload while maintaining high standards of care, compliance, and accountability
• Strong interpersonal, organizational, and problem-solving skills
Core Competencies
• TBI-focused care and understanding of cognitive and behavioral impacts
• Care coordination with an emphasis on accountability and outcomes
• Strong clinical judgment and decision-making
• Ability to identify risks and escalate concerns appropriately
• Knowledge of home care operations and community-based service systems
• Professional communication and interdisciplinary collaboration
• Crisis intervention and problem-solving
• Documentation accuracy and regulatory compliance
• Accountability, ownership, and follow-through
• Relationship-building with clients, families, and care teams
• Adaptability in fast-paced, field-based environments
Always Compassionate Health is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment. All employment decisions at Always Compassionate Health are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, creed, national, social or ethnic origin, political viewpoint, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, protected veteran status, citizenship status when otherwise legally able to work, or any other status protected by the laws or regulations in the locations where we operate.
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