Social Worker, Community Health

MAJOR RESPONSIBILITIES

• Conducts complete assessments, establishes appropriate plans , and initiates interventions within desired time frames . Collaborates and negotiates effectively with patient , family, and team while striving to achieve patient and organizational goals with regard to patient’s care needs, choice and satisfaction when discharge planning/transitioning care. Utilizes patient/family strengths in the problem-solving process, involving the patient/family and team in the decision-making process beginning on admission and continuing throughout patient’s hospital stay.

• Provides social work services to patients, families, and individuals including psychosocial assessment, screening, determination of needs evaluation, appropriate interventions and follow up , and discharge planning. Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources and payer network.

• Participates as part of the multi-disciplinary health care team to develop safe and timely coordination of care including but not limited to post-acute placement, palliative/hospice service lines, medical equipment, home healthcare, outpatient follow up, mental health resources, and other community resources. Advocates for patient involvement in the plan of care. Initiates and coordinates interventions with the activities of other members of the health care team.
  
  Remains knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay and community resources.

• Completes UM activities as required based on local structure to include providing clinical updates to payers and/or external review organizations, collecting data, coordinating denial activity, supporting UM activity, and managing avoidable delays. Delivers CMS regulatory notices within CMS established time frames , as appropriate based on-site guidelines.

• Communicates effectively with the healthcare team. Works in partnership with RN Care Manager and unlicensed support personnel to effectively establish and implement a safe plan of care. Serves as an active member of the MDR and works closely with medical staff, hospital departments and ancillary services in identification and resolution of barriers to discharge, expediting care delivery to avoid delays in timely service provision, and implementing and reporting care coordination, discharge planning and utilization management (UM) activities.

• Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educating patients and families on these issues as appropriate . Connects patients to appropriate agencies on issues of suspected abuse and neglect, domestic violence, guardianship, and other social matters.

• Provides resources to patients and families to ensure a timely discharge and to provide an appropriate link with post-acute care providers and services.

• Provides support and connection to additional services such as bereavement and loss, ethical issues, advanced directives, and end of life issues.

• Collaborates with community agencies and institutions to plan continued care and to coordinate interventions. Provides resources and education to patients and families regarding appropriate resources and access to community social services.

• Communicates effectively with patients, family, other members of the health care team and community agencies and facilitates resolution of issues which could impact on continuity of care (e.g., prior-approvals, application requirements, transfer paperwork). Documents activity according to department and program protocols or standards. Manages the progression of patients stay with the goal of optimizing the LOS…