Care Coordination Master Social Worker

4 weeks ago Be among the first 25 applicants

JOB SUMMARY / PURPOSE

The Masters Social Worker is responsible for performing social work assessments and interventions as needed for hospitalized and emergency department patients. The functions of the Masters Social Worker include: crisis intervention, patient/family intervention, high-risk screening, brief counseling, referrals for financial or other identified resource needs, arrange and facilitate family/patient representative meetings with the health care team as needed, arrange post-acute placement on complex discharges and engagement of appropriate agencies or community resources when high-risk patients are identified.

• Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients.
• Advocacy and education: patient/family self-care management; patient/family health management education; bioethics referrals and management; physician, staff, and community education; case/care management/coordination education and training; risk management identification and referral.
• Psychosocial management: crisis intervention; psychosocial assessment/functioning; counseling support and referral; abuse/neglect/trafficking identification, assessment, and referral (partner, child, elder, etc.); family issues affecting care; coping/emotional adjustment; grief/bereavement support (individual and group); adoption, surrogacy, and safe surrender support, management, and resources; health/wellness promotion; substance abuse screening, management, and resources; psychiatric screening, management, and resources; staff support; assessing, addressing, managing, and resources related to social determinants of health (e.g. housing and food insecurity, transportation).
• Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management.
• Continuity/Transition Management:
  As part of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to clinical social work scope of service and functions and social worker discretion; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; grave disability, palliative care/end-of-life, and hospice patient/family support, referrals, and management;
  
  interventions, management, and coordination of transition planning for psychosocially complex cases.
• Community Resource Coordination: life-care planning; expert consultation on health care resource management; team and patient education regarding various health-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social determinants of health needs.
• Performance & Outcomes Management: in-depth understanding and application of federal/state/local regulatory agency guidelines, The Joint Commission standards, and other regulatory and accreditation requirements; implement evidence-based practices; support organizational financial performance, length of stay, cost per case, readmission prevention efforts and revenue cycle goals.
• Provide support and social work services to outpatients if directed by Care Coordination leaders.
• Participates in performance improvement teams and programs as necessary.
• Demonstrates behavior that aligns with the Mission and Core Values of the Organization.
• Responsible for completing required education within established time frames.
• Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
• Performs other duties as assigned.

Required: Master’s degree from a school of social work accredited by…