Clinical Social Worker

The Clinical Social Worker acts as a patient advocate to SSH & SSMC clients. Works in coordination with the RN Case Manager to coordinate, negotiate, procure services and resources for and manage the transitional care planning of patients to facilitate achievement of quality and cost-effective patient outcomes.

Responsible to work with a multi-disciplinary patient care team to optimize care coordination, behavioral and mental health and wellness, monitor patients through admissions, ED visits and collaborate with other stakeholders to transition home/to the community post discharge. This role requires varying degrees of follow-up and follow through, including fostering, executing, and expediting efficient care coordination and assessing the needs of patients and families.

Works collaboratively with the interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. Utilizes SMART GOAL formation and clear, precise documentation regarding patient outcomes and interventions. The Social Worker is on site and available 4-5 days a week as well as some holidays; no nights, weekends or on-call hours required.

Does this position have Patient contact? Yes

• Adolescents 13 - 18 yrs YES
• Children 1 - 12 years YES
• Adults 19 - 70 years YES
• Geriatrics 70+ years YES

Master's required. Must be independently licensed. Demonstrates competency in basic computer and keyboard skills required, EPIC and Outlook preferred. Knowledge of basic medical terminology preferred.

Recent healthcare experience or related field preferred. Experience working with pediatric patients and families, elders and their caregivers, and/or various other community populations desirable. Social worker experience required.

LICSW – Independently Licensed Certified Social Worker or

LMHC – Must be independently licensed

Excellent communication skills required: ability to work independently and autonomously. Ability to manage time, set priorities and self-origination will be essential to success of employee. Ability to work within a multidisciplinary team and in collaboration with the RN Case Manager and supporting staff.

Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions that the person in the job is held accountable for. Following are the essential functions of the job.

a
- Respond to and prioritize urgent high-risk cases such as

• Crisis interventions
• Depression Screening referrals
• Pedi BH referrals
• Adult Protective Service (APS) and/or Child Protective Service (CPS) referrals
• Guardianship referrals

b
- Coordinate appropriate community and resource specific referrals

• Financial
• Educational
• Counseling/family support agencies

C
- Complete and document initial psychosocial assessment if required in Electronic Medical Record (EMR) on identified patients within 24 hours of patient admission/one business day or within 24 hours of referral

a – Review work list/census to prioritize patients and identify those that meet criteria for social work interventions as needed; (attending Monday morning CMS Teams Huddle on upcoming patients)

b – Review patients in settings:

• ED when necessary
• Skilled Nursing Facilities – as needed for staff consult
• Coordination with VNA/Home Health or Family support when patient has…