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It’s inspiring to work with a company where people truly BELIEVE in what they’re doing! When you become part of the Chapters Health Team, you’ll realize it’s more than a job. It’s a mission. We’re committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success!Role: The Social Worker (SW) provides and coordinates a wide range of social services including psychosocial support to patients and their families.Qualifications:<ul><li>Master’s degree or above in Social Work (CSWE accredited); SWs hired before 2009 who have degrees in other fields are grandfathered in; SWs hired before 4/21/2019 who have BSWs are grandfathered in; Bachelor’s degree may be considered depending on geographic area (Note: Home Health requires MSW)</li><li>Employees working in Georgia require current Georgia LCSW</li><li>Minimum of one (1) year of experience including social work/counseling internship in health care or hospital setting</li><li>Familiarity with and working knowledge of the concepts and practices of both adult and pediatric patients:&nbsp;&nbsp; Hospice: death and dying &nbsp;Palliative: serious illness</li><li>Previous experience working with an EMR/EHR (Electronic Medical/Health Record) system</li><li>Experience in children, family, and group modalities</li><li>Ability to manage multiple priorities simultaneously and effectively handle the emotional stress of the workload</li><li>Able to remain calm, professional, trouble shoot and intervene with patient/family crisis situations.</li><li>Able to demonstrate high ethical standards in areas of Hospice mission, confidentiality, sensitivity, and flexibility</li><li>Excellent communication (verbal and written) and interpersonal skills</li><li>Ability to work in a team environment and intervene appropriately</li><li>Mobile Driver - Valid driver's license and automobile insurance per Company policy</li><li>Ability to travel to off-site locations</li><li>Ability to physically access any home, hospital, clinic, nursing home, and assisted living facility (i.e., navigate stairs, narrow stairs, narrow spaces, lack of air conditioning, etc.)</li></ul>Competencies:<ul><li>Satisfactorily complete competency requirements for this position.</li></ul>Responsibilities of all employees:<ul><li>Represent Company professionally at all times through care delivered and/or services provided to all clients.</li><li>Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.</li><li>Comply with company policies, procedures and standard practices.</li><li>Observe company's health, safety and security practices.</li><li>Maintain the confidentiality of patients, families, colleagues and other sensitive situations within company.</li><li>Use resources in a fiscally responsible manner.</li><li>Promote company through participation in community and professional organizations.</li><li>Participate proactively in improving performance at the micro and macro levels.</li><li>Improve own professional knowledge and skill level.</li><li>Advance electronic media skills.</li><li>Support company research and educational activities.</li><li>Share expertise with co-workers both formally and informally.</li><li>Participate in Quality Assessment and Performance Improvement activities as appropriate.</li></ul>Job Responsibilities:<ul><li>Performs and documents psychosocial assessment.</li><li>Empowers patient/families to negotiate with resource providers and make decisions on their own behalf.</li><li>Assists other clinical staff in (1) understanding family dynamics as well as significant social and emotional factors related to health problems and (2) developing a plan to address issues in a nonjudgmental manner.</li><li>Maintains documentation in a manner that reflects timeliness, completeness, accuracy, legibility, clarity of goals and interventions.</li><li>Consults and collaborates with other professionals to promote quality care and continuity of patient/family care.</li><li>Performs other duties as assigned.</li></ul>Home Health Specific:<ul><li>Participates in the development of the individualized Plan of Care and participates in Case Conferences.</li><li>Observes clinical symptoms, reaction to treatment regimen, and emotional status and reports to the appropriate staff along with pertinent changes.</li><li>Anticipates barriers to pain and symptom management; identifies differences in goals of curative and palliative care; and provides appropriate education.</li><li>Respects patient’s wishes and stated goals when planning and providing care.</li></ul>Hospice Specific:<ul><li>Shares joint responsibility with other clinicians and volunteers to provide care to patients and families including psychosocial support, advanced directive information, development of Plan of Care, and other social services depending on the patient/family needs.</li><li>Attends and participates in Interdisciplinary Group (IDG) meetings; assists in developing and updating the Plan of Care; facilitates understanding of social services and bereavement aspects of care, and provides team with goals and interventions for patient/family care.&nbsp;</li><li>Evaluates bereavement needs including making condolence calls, evaluating risk and coordinating the Plan Care with Bereavement staff.</li></ul>Palliative Care Specific:<ul><li>Assists the palliative care team and/or directly facilitates patient-family meetings for goal setting and advance care planning.</li><li>Provides emotional support for patients and families facing serious illness.</li><li>Coordinates educational and outreach services relevant to the social services – palliative care interface.</li><li>Provides liaison function: (1) between system-wide outpatient palliative care team and inpatient palliative care team, discharge planning and social service departments and (2) between palliative care team and community hospice, home care agencies, long term care facilities and other community services.</li></ul>Job Description Addendum for Social Worker in the Florida Keys &amp; North Florida (3A):Duties may also include performance in bereavement counseling and volunteer coordination.<ul><li>Evaluates the bereavement care needs for survivors (i.e., adults, children, families) in accordance with Company policy.&nbsp; Provides grief guidance and support to maintain the Plan of Care.</li><li>Facilitates bereavement and holiday support groups for children and adults.&nbsp; May attend memorial services.</li><li>Maintains bereavement documentation in a manner reflecting timeliness, completeness, accuracy, legibility, clarity of goal, evaluation, plan, and intervention.</li><li>Recruits volunteers through community networking activities and marketing efforts.&nbsp; Screens potential volunteers through intake calls and interviews, and in training.</li><li>Trains, assigns, supervises and evaluates patient/family care volunteers as well as volunteers for Social Services/Bereavement, events, administrative support, and various other roles.</li><li>Participates in the development and implementation of programs which enhance the morale and effectiveness of volunteers, volunteer newsletter, volunteer in-services, support programs and annual volunteer recognition.&nbsp; Participates in volunteer-related special events, committees and task force groups.</li><li>Maintains records of volunteers, ensuring that all file requirements are met and kept current.</li><li>Participates in interdisciplinary group (IDG) meetings; providing feedback about patients and family members and serves as a liaison between team members and volunteers.</li></ul>Compensation Pay Range: $53,623.86 - $80,435.79This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.

Chapters Health System

Social Worker

It’s inspiring to work with a company where people truly BELIEVE in what they’re doing! When you become part of the Chapters Health Team, you’ll realize it’s more than a job. It’s a mission. We’re committed to providing outstanding patient care and a high level of customer service in our communities every day. Our employees make all the difference in our success!Role: The Librus APRN is a key clinical leader in the delivery of person-centered, value-based care to Institutional Special Needs Plans (ISNP), ACOs, and high-risk payors residing in Skilled Nursing Facilities, communities, or private homes. Working in alignment with the payor's model of care and under the Librus program, the APRN performs comprehensive clinical assessments, closes care gaps, participates in IDT meetings, ensures accurate HCC coding, reduces unneeded hospitalizations, and delivers high-quality primary and supportive care to medically complex patients. This role also includes providing end-of-life services, including comfort and symptom-focused care without formal hospice enrollment, ensuring quality of life and dignity are prioritized during serious illness and advanced aging.Qualifications: Required:<ul><li>Licensed APRN with active certification (Adult/Geriatric NP, FNP, or similar) in the state of Florida.</li><li>DEA license with prescriptive authority.</li><li>Minimum 3 years of experience as a nurse practitioner, preferably in geriatrics, SNF, hospice, palliative care, or complex care management.</li><li>Demonstrated experience with HCC coding and risk adjustment models.</li><li>Familiarity with Medicare Advantage care gap closure metrics.</li></ul>Preferred:<ul><li>Experience with ISNPs, D-SNPs, or other value-based Medicare models.</li><li>Knowledge of SNF workflows and interdisciplinary care teams.</li><li>Comfort and skill in end-of-life conversations and palliative approaches.</li></ul>Schedule &amp; Travel:<ul><li>Full-time, Monday–Friday with flexibility for urgent needs</li><li>On-site presence in designated SNFs with occasional local travel</li><li>Minimal on-call rotation, shared with other advanced practice providers</li></ul>Competencies:<ul><li>Advanced clinical assessment and diagnostic skills</li><li>Coding and documentation proficiency (HCC, SOAP, risk adjustment)</li><li>Compassionate care mindset with emotional intelligence</li><li>Collaborative leadership across multiple teams</li><li>Strategic time and case management abilities</li></ul>Responsibilities of all employees:<ul><li>Represent the Company professionally at all times through care delivered and/or services provided to all clients.</li><li>Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.</li><li>Comply with Company policies, procedures and standard practices.</li><li>Observe the Company's health, safety and security practices.</li><li>Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.</li><li>Use resources in a fiscally responsible manner.</li><li>Promote the Company through participation in community and professional organizations.</li><li>Participate proactively in improving performance at the organizational, departmental and individual levels.</li><li>Improve own professional knowledge and skill level.</li><li>Advance electronic media skills.</li><li>Support Company research and educational activities.</li><li>Share expertise with co-workers both formally and informally.</li><li>Participate in Quality Assessment and Performance Improvement activities as appropriate for the position.</li></ul>Job Responsibilities: Clinical Care Delivery:<ul><li>Serve as the primary advanced practice provider for assigned ISNP members, High-Needs ACO patients, and similar settings, delivering direct, evidence-based care in collaboration with facility and plan/payor staff.</li><li>Perform routine and urgent clinical assessments, diagnose and manage chronic and acute conditions, and adjust care plans.</li><li>Provide palliative and hospice-like care interventions focused on comfort, dignity, and patient-centered goals.</li></ul>HCC Coding &amp; Gap Closure:<ul><li>Conduct comprehensive annual and episodic assessments to ensure accurate capture of chronic conditions per CMS HCC guidelines.</li><li>Close quality gaps related to screenings, labs, immunizations, and chronic disease management per ISNP, Payor and plan metrics.</li><li>Maintain thorough, compliant documentation to support both care delivery and risk adjustment requirements.</li></ul>Model of Care Alignment:<ul><li>Operate as a clinical champion of the Librus Model of Care, emphasizing proactive interventions, interdisciplinary collaboration, and reduced avoidable hospitalizations.</li><li>Partner with the RN Care Coordinator and facility teams to ensure service continuity, integration, and alignment.</li></ul>Advanced Illness Management:<ul><li>Lead or participate in goals-of-care discussions, advance directive review, and shared decision-making with patients and families.</li><li>Support members through end-of-life transitions with empathy and skill, even without formal hospice enrollment.</li><li>Utilize comfort-focused prescribing and symptom management protocols.</li></ul>Collaboration &amp; Reporting:<ul><li>Attend IDT meetings and collaborate regularly with payor physicians, SNF staff, and Librus leadership.</li><li>Communicate care plans effectively with patients, caregivers, and staff.</li><li>Submit timely and accurate clinical documentation, coding, and quality reporting.</li></ul>This position requires consent to drug and/or alcohol testing after a conditional offer of employment is made, as well as on-going compliance with the Drug-Free Workplace Policy.

2 Healthcare Jobs in Hillsborough County