Medical Social Worker (MSW)- PACE

Blue Ridge Care; Winchester, Northern (VA, KY); Hybrid; USD 55,000 - 75,000; Full time

Benefits offered by this job

Competitive Pay

PTO & Volunteer Time

Health, Dental & Vision Benefits

Tuition Reimbursement

Peer Support

Thrift Shop Discount

Growth Opportunities

Job summary

Blue Ridge Independence at Home is seeking a Medical Social Worker (MSW) to join the interdisciplinary team and support older adults and their families in living safely and independently in the community.

The role involves psychosocial assessments, care planning, discharge coordination, and home visits, with focus on counseling, advocacy, and problem-solving for complex needs. A Master’s in Social Work and relevant experience are required.

Qualifications

• Master’s Degree in Social Work from an accredited program.
• At least one year of experience providing services to older adults or individuals with developmental or physical disabilities.
• Case management experience preferred.

Responsibilities

• Complete psychosocial assessments for prospective and current participants.
• Develop individualized care plans and update them as needs change.
• Coordinate case management and discharge planning, including transitions of care between home, hospital, and other care settings.
• Complete home visits and home assessments.
• Participate in interdisciplinary team meetings and collaborate on care decisions.
• Support families with problem-solving, communication, and caregiving challenges.
• Provide counseling, crisis intervention, and advocacy.
• Assist with housing concerns, benefits navigation, and financial eligibility issues.
• Maintain accurate and timely case documentation in the EMR.
• Help participants complete advance directives or guardianship paperwork.
• Participate in cross-site meetings, trainings, and quality initiatives.
• Protect participant confidentiality and uphold ethical practice standards.
• Provide coverage for other sites as needed

Skills

Assessment skills

Counseling

Communication skills

Documentation skills

Driver’s license

CPR certification

Education

Master’s Degree in Social Work

Tools

EMR

Job description

Medical Social Worker (MSW) - PACE

Blue Ridge Independence at Home is part of Blue Ridge Care’s Program of All-Inclusive Care for the Elderly (PACE). Our team brings together clinicians, therapists, personal care aides, and care coordinators who share one purpose: supporting older adults in living safely and independently in the community.

If you value meaningful relationships, collaborative teamwork, and serving those who need you most, this may be the role for you.

About the Role

We’re looking for a Social Worker with a Master’s in Social Work who is ready to make a real impact in the lives of our participants and their families. In this role, you’ll provide case management, counseling, advocacy, and care coordination as part of our interdisciplinary team. You’ll help participants strengthen independence, navigate complex care needs, and stay connected to their community.

What You’ll Do

• Complete psychosocial assessments for prospective and current participants

• Develop individualized care plans and update them as needs change

• Coordinate case management and discharge planning, including transitions of care between home, hospital, and other care settings

• Complete home visits and home assessments

• Participate in interdisciplinary team meetings and collaborate on care decisions

• Support families with problem-solving, communication, and caregiving challenges

• Provide counseling, crisis intervention, and advocacy

• Assist with housing concerns, benefits navigation, and financial eligibility issues

• Maintain accurate and timely case documentation in the EMR

• Help participants complete advance directives or guardianship paperwork

• Participate in cross-site meetings, trainings, and quality initiatives

• Protect participant confidentiality and uphold ethical practice standards

• Provide coverage for other sites as needed
  

What You Bring

• Master’s Degree in Social Work from an accredited program

• At least one year of experience providing services to older adults or individuals with developmental or physical disabilities

• Case management experience preferred

• Strong assessment, counseling, and communication skills

• Ability to work independently while thriving in a team environment

• Comfort navigating complex family dynamics and problem‑solving needs

• Strong computer and documentation skills

• Valid driver’s license, vehicle insurance, and reliable transportation

• CPR certification (active and up to date)

• Ability to meet medical clearance and immunization requirements
  

Schedule

Typically Monday–Friday, 8:30 a.m.–4:30 p.m., with occasional needs outside standard hours.

Why Join Us?

At Blue Ridge Independence at Home, you’ll be part of a mission‑driven team committed to dignity, compassion, and supporting each participant’s journey. Your work will directly improve the lives of older adults and their families every day.

Benefits

• Competitive Pay

• PTO and Paid Volunteer Time

• Comprehensive Health, Dental & Vision Benefits

• Tuition Reimbursement & Scholarships

• Peer Support & Mentorship

• 30% Thrift Shop Discount

• Growth Opportunities through the Blue Ridge Care 2030 Strategic Plan

Blue Ridge Care is a non-profit, equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees and patients served.