• Social Worker-Field

    Job Locations US-TN-Nashville
  • Overview



    Aspire Health is the nation’s leading non-hospice community-based palliative care provider. Aspire specializes in providing an extra layer of support to patients facing a serious illness through an ambitious palliative care program focused on caring for patients in their homes and outpatient clinics. Aspire’s clinicians are experts in providing patients with relief from the symptoms, pain, and stress of a serious illness; helping patients and caregivers navigate the healthcare system; guiding patients and caregivers through difficult and complex treatment choices; and providing emotional and spiritual support to patients and their families. Our core values are Clinical Excellence, Compassion, Teamwork, and Going the Extra Mile!


    Aspire Health is seeking a social worker who will be responsible for providing supportive and medical social services to patients and their families in the home. This will include a range of tasks such as directly providing support to Aspire’s patients and families in the home as well as coordinating patient transition from facility to the home. The Aspire Social Worker assists the medical team in creating comprehensive psycho-social assessment and support services to patients and families, as well as care plans that are sensitive to the patient’s unique psychosocial needs, health status, and overall goals and values. 
    Ideal candidates will have experience identifying and coordinating the needs of chronically ill patients and families as well as supporting clinicians to help them operate as efficiently as possible. Responsibilities will be highly varied, and appropriate candidates will be multitalented, flexible problem solvers who are eager to tackle complex problems and tasks.


    Provide in-home and telephonic psychosocial assessment and supportive services to patients and families as part of an interdisciplinary team. Care coordination with the patient, family, caregivers, and other providers includes:
    Supporting hospice consultation and transition
    Social support and transportation needs
    Financial counseling
    Identifying non-clinical community resources
    Mitigating family dynamics and patient compliance issues
    Assess, identify and close clinical and non-clinical gaps in patient care
    Appropriate triage and escalation of routine, urgent and emergent patient calls
    Document social work assessments, care plans, and interventions
    Initiating health plan authorization for Home Health, DME, Home Infusion and other critical services. Verifying the timely delivery of these services.
    Collaboration with field based NPs/PAs and physicians to develop and implement effective treatment plans and interventions for complex patient care issue
    Identifying community resources and assisting Aspire’s patients and families in accessing those resources. 
    Referral to Aspire Health chaplain resources when appropriate.  Provide grief support and reassurance to patients and family members.  Various clinical and administrative tasks.  Participation in weekly interdisciplinary team meetings.  Other related duties as deemed necessary by Aspire Health.  


    A successful candidate will have minimum of 3 years social work experience (required), preferably in a centralized care management team environment.  Master’s degree in social work and licensure at that level (required).  Prior healthcare experience serving chronically ill patients living with limited resources, serious emotional disturbance, and/or mental illness (preferred).  Health plan, home health, or hospice experience (preferred).  Should be excited and energized by the prospect of working collaboratively as part of an innovative team to build a new palliative care delivery model.   Telephonic case management or care coordination experience (preferred).  Strong customer-service orientation.  Patient, compassionate and professional demeanor (required).  Exceptional organizational skills and ability to multi-task
    Self-starter with an entrepreneurial spirit and demonstrated problem solving skills.   Strong writing, Word, Excel, and database management skills.  Extremely strong work ethic.  Experience working in a fast-growing, rapidly changing environment. 


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