Clinical Social Worker | Care Coordination

Overview

The Clinical Social Worker provides and coordinates psychosocial and behavioral services for assigned group of patients. The Clinical Social Worker assesses, plans, implements and monitors a plan of care for assigned group of patients. This is done in collaboration with other members of the medical team, i.e., physicians, nurses, case managers, PT/OT staff and pharmacists. Works with the care team in a designated setting to identify and, when possible, advocate for the patient.

Works to provide direct services, resources and counseling that a patient/client needs to create a safe, effective and efficient transition/discharge from the hospital or clinic. Provides expertise in a crisis intervention situation and assesses for potential abuse/neglect of vulnerable patients.

• Identifies appropriate discharge social work needs for assigned patients (providing resources, community support, ensuring advance directives/next of kin is identified).
• Partners with community agencies to coordinate care across the continuum to offer options, tools, and resources to allow patients the opportunity to achieve the desired goals.
• Assists with patient evaluation and treatment to further their understanding of significant social and emotional factors underlying a patient’s health problem(s).
• Acts as a patient advocate: investigates and reports adverse occurrences and performs staff education related to resource deployment, discharge planning and psychosocial aspects of healthcare delivery.
• Assists care team and family with end of life conversations, offers grief counseling, and performs hospice consults
• Assist with determination when care conference is appropriate; coordinates scheduling with team & caregivers
• Plan and support patients in coping with emotional, economic, social, and environmental challenges.
• Assess for the need/eligibility for financial assessment and refer to the appropriate programs.
• Performs discharge planning activities, including referrals to Home Health, Skilled Nursing, Inpatient Rehab, DME, etc. for assigned patients.
• Documents patient data, plan, interventions and outcomes according to department guidelines.
• Performs all other duties as assigned by management within job scope.

• Education required:
  
  Master’s Degree in Social Work or related field
• Experience
  
  Required:
  
  1 year of recent clinical experience applicable to the designated population served
• Preferred: LCSW
• Preferred:
  At least 1 year experience in a healthcare setting