Social Worker​/Discharge Planner

Social Worker/Discharge Planner - 31875

We are currently looking for a Full Time Social Worker/Discharge Planner to join our Inpatient Case Management and Social Worker Team team located at the Chickasaw Nation Medical Center working 8:00AM-5:00PM
- Mo Tu We Th Fr.

The social worker/discharge planner collaborates on complex, prospective transitional plans and provides discharge planning for patients transitioning to nursing home settings. This position is responsible for completing bio-psycho-social assessments, treatment planning, patient advocacy, and counseling related to illness impact, care plan compliance, advance directives, and legal or ethical considerations. The position also provides crisis intervention for issues such as abuse, neglect, domestic violence, substance use, trauma, and homelessness, while identifying barriers to safe and appropriate transitions of care.

Additionally, the role participates in variance collection, monitoring, and reporting to support continuous improvement in patient care processes, outcomes, and overall quality.

Responsibilities:

• Works with case management for managing, planning, integrating, coordinating and controlling the functions of care management within the Chickasaw Nation Department of Health (CNDH)
• Generates and faxes/copies patient protected health information necessary for continuation of care to outside healthcare facilities and/or providers, ensuring that all records needed for this process are accurate and valid, while maintaining patient confidentiality, security and integrity of data and information in accordance with HIPAA and the Minimum Necessary Rule, and noting within the patient's EHR each disclosure according to CNDH documentation policy
• Oversees the daily management of social work functions by assessing, planning and organizing social services within a framework of established guidelines/protocols, health status of patients, and available funds/resource
• Develops and implements the medical social work function to ensure continuity of care, decrease fragmentation of services, and enhance health promotion disease prevention activities
• Identifies and screens cases, determines the availability of community resources, evaluates the status of the patient's mental and physical capabilities and provides coordination
• Provides skilled medical social work and psychosocial services to patients, their families, and/or caregivers
• Documents in the medical record for the purposes of treatment and referral options and shares clinical information with providers and other health care professionals
• Works closely with the medical staff to coordinate patient discharge with an assurance of coordination of care following discharge, when needed
• Counsels patient/family as necessary and as privately as possible regarding psychosocial and environmental adjustments related to medical conditions
• Serves as a resource for nurses, providers, and the patient/family during the coordination process and discharge planning
• Works to integrate social work activities within the discharge planning process
• Works as a member of the multidisciplinary patient care team
• Develops good working relationships with patients, hospital staff, and community resources
• Works with case managers to assess discharge readiness of patients
• Serves as the patient advocate in representing the patient's best interest during the coordination of care process
• Ensures that social work activities are ethical and to the value to the patient, their family, and providers of care both within and outside the health system
• Provides leadership in the development of policies, procedures, and protocols related to medical social work services
• Provides clinical and program consultation to CNDH patients, other healthcare professionals, providers, as well as other divisions within the tribe and community
• Serves on hospital committees as assigned
• Provides care appropriate to the age of patients served
• Assists in orientation and education of department personnel
• Demonstrates improvement in areas of performance or progress/accomplishment of goals identified in previous performance evaluation
• Adheres to organizational and departmental standards and policies
• Assists in identifying activities and data collection for performance improvement
• Provides first class customer service to both internal and external customers and responds to inquiries, compliments, and/or complaints with professionalism, courtesy, and efficiency
• Completes all training and development requirements and participates in continuing education opportunities
• Works in a collaborative and supportive manner to support the productivity and safety of the work area, team members and customers of all types
  - Maintains a clean, organized work area and ensures a safe environment
  - Maintains and promotes professionalism
  - Punctual and consistent in meeting start time, work schedule, attendance and other assigned work time metrics
  - Adheres to Chickasaw Nation dress code standards
• Maintains knowledge of and…