Clin Care Social Worker

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Sign-On Bonus Eligible

This position comprehensively plans for the coordination of care for the WVU Medicine patient population across the continuum. Performs psychosocial assessments, crisis intervention, resource management, discharge planning, care facilitation, and referrals to alternate levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes. The position intervenes with patients who have complex psychosocial needs, require assistance with eligibility determination for social programs and funding sources, and qualify for community assistance from a variety of special funds and agencies.

In addition, may offer crisis intervention to patients and families with psychosocial needs and collaborates with the patient care team in the development of a transition/discharge plan of care for all patients.

1. Masters degree in Social Work

2. Current social worker licensure as required by the state where work is being performed.

Licensed Graduate Social Worker (LGSW), Licensed Certified Social Worker (LCSW) or Licensed Independent Social Worker (LICSW) through the West Virginia Board of Social Work

Licensed Masters Social Worker (LMSW) or Licensed Certified Social Worker - Clinical (LCSW-C) through the Maryland Board of Social Work

1. One to three years of experience preferred

1. Manages all aspects of transition/discharge planning for assigned patients in a timely manner using escalation processes as needed when barriers encountered.

2. Collaborates with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload.

3. Monitors the patient's progress; intervening as necessary and appropriate, to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.

4. Maintains extensive knowledge of federal, state, and local assistance programs and community resources that affect patient needs.

5. Demonstrate appropriate professional practice, maintaining respect for confidentiality and freedom of choice as outlined by the Code of Ethics by the National Association of Social Workers as well as the State Board of Social Workers.

6. Provides education as needed to staff, physicians, and patients and their families to ensure effective transition planning.

7. Meets directly with the patient and/or family to assess needs and develop an individualized transition/discharge plan in collaboration with the physician team.

8. Provides social work assessment and interventions for complex crisis including but not limited to mental health, substance abuse, adjustment to health status and grief/loss situations.

9. Communicates with the multidisciplinary team and post-acute providers when applicable, any complex family dynamics that may directly impact patient care and transition/discharge planning.

10. Initiates and facilitates referrals to post‑acute services- including but not limited to
- Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities.

11. Communicates all necessary information regarding transition/discharge plan to the multidisciplinary team, patient and family. Assists other team members to understand and appreciate a patient and/or family's reaction to a serious illness and/or chronic illness/disease as well as to understand other environmental factors affecting care, treatment and compliance.

12. Provides timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to regulatory policies and procedures.

13. Working knowledge of patient's current medical insurance coverage and…