• Conducts comprehensive psychosocial assessments to identify patient and family strengths, barriers, and support needs through video technology and telephone calls • Provides grief and bereavement support to patients and families, including anticipatory grief counseling and funeral service assistance • Screens for and addresses mental health concerns including depression, anxiety, and caregiver stress • Assesses for safety risks including suicide ideation, abuse, neglect, and unsafe living conditions • Participates in weekly interdisciplinary team (IDT) meetings to discuss patient care plans • Provides medical social work case management to a given group of patients and their families • Assesses and responds to the psychosocial, practical, financial, and legal concerns of the patients and families/support systems • Assists patients and families in accessing and using community resources • Assists patients and families with the navigation of social and healthcare systems • Mediates conflicts between families and care networks • Completes financial needs assessments and assists with navigation on MediCare, MediCal, Disability and Social Security and Veterans Affairs benefits • Assesses for spiritual and medical needs and communicates these promptly to interdisciplinary team • Establishes and maintains relationships with community resources • Identifies problems, goals, interventions and frequency of visits to complete the social work Plan of Care • Facilitates advance care planning, including advance directive and POLST completion • Completes documentation within 48 hours • Assumes other duties in support of Vynca’s needs as directed by the Clinical Manager or Chief Medical Officer • Assists with community outreach and education regarding Vynca services • Ability to travel to perform job duties, attend training, or company events