Social Worker

Location US-MI-Troy
ID 2023-2500
Nursing & Clinical
Position Type


HarmonyCares is one of the nation’s largest home-based primary care practices. HarmonyCares is a family of companies all dedicated to providing high-quality, coordinated health care in the home. This includes HarmonyCares, HarmonyCares Medical Group, HarmonyCares Home Health and HarmonyCares Hospice.


Our Mission – “Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services”


Our Values – Respect, Integrity, Teamwork and Excellence - are leading us to a better tomorrow for patient care. 


Why You Should Want to Work with Us

  • Quarterly Bonuses – up to $5000 per year!
  • Health, Dental, Vision, Disability & Life Insurance, and much more
  • 401K Retirement Plan (with company match)
  • Tuition, Professional License and Certification Reimbursement
  • Paid Time Off, Holidays and Volunteer Time
  • Paid Orientation and Training
  • Day Time Hours (no holidays/weekends)
  • Great Place to Work Certified
  • Established in 11 states
  • Largest home-based primary care practice in the US for over 28 years, making a huge impact in healthcare today!


The Social Worker, Medical Group works collaboratively with the Care Team to provide care management services based on comprehensive assessments addressing an individual’s ability to maintain independence in the home, chronic care management, end of life decisions, Social Determinant assistance, and a patient/caregiver support system. As a Social Worker, Medical Group you will:

  • Manage a caseload of high risk socially complex patients
  • Conduct face to face and telephonic psychosocial assessment with the patient and/or the caregiver
  • Investigate psychological and social determinant barriers and design appropriate interventions to assist in closing gaps in care and needs
  • Assist in the design of appropriate interventions to assist in closing gaps in care and needs
  • Coordinate services to ensure the patient/family understands a treatment plan
  • Provide outreach to community based services to support the patient’s ability to age at home
  • Assist in the development and implementation shared goals of care with the patient and family
  • Provide feedback to the home based primary care physician (HBPCP) to ensure he/she is aware of any early patient changes
  • Participate in Multidisciplinary Care Planning Rounds
  • Conduct additional assessments as patient needs change
  • Work with Community based agencies to develop relationships and provide appropriate resources to assist in maintaining patient independence
  • Other duties/projects as assigned
  • Participates in quality improvement activities aimed to improve patient-population outcomes and associated processes


Required Knowledge, Skills and Experience 

  • Master’s Degree in Social Work (MSW) from a school of Social Work accredited by the Council on Social Work Education
  • Current unrestricted Social Work License in the state of practice in accordance with the state licensure requirements
  • 3 years of experience in Care Management in community based setting or equivalent
  • Must maintain a valid driver’s license and good driving record
  • The ability to use sound clinical judgment and communicate clearly in both written and verbal formats
  • Above average computer skills
  • Ability to be self-directed and able to communicate effectively with professional staff across many disciplines and programs
  • Must have the ability to plan time effectively, balance multiple tasks, work within stringent time frames, resolve problems, identify patient service trends, determine system improvements, and implement change
  • Ability to share expertise with others and demonstrates an understanding of the need to foster performance improvement while achieving patient satisfaction and efficiency
  • Experience with the homebound population, managed care, ACO, medical home or integrated case management environment is preferred

Preferred Knowledge, Skills and Experience 

  • Experience working with the chronic, complex and/or behavioral health population



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