CD Patient Care - Continuing Care - Medical Social Worker; BSW or MSW); On-Call, MMMC

Provides social work services, including psychosocial assessment, discharge planning, care coordination, and resource navigation for patients and their families. Collaborates with the interdisciplinary team to ensure safe transitions of care and addresses psychosocial needs during hospitalization. Serves as liaison between Maui Health System (MHS) and community agencies to integrate services and enhance patient outcomes.

• Conduct psychosocial assessments to identify patient and family needs related to hospitalization, discharge planning, and community resources.
• Develop and implement social work service plans focused on resource needs, support systems, and care transitions.
• Coordinate discharge planning and care transitions, including referrals to appropriate providers, to ensure safe and timely discharge to home or post-acute care settings.
• Manage socially complex cases involving barriers to discharge such as homelessness, behavioral health concerns, substance use, guardianship, abuse/neglect, or lack of caregiver support.
• Collaborate with community agencies and legal resources to address complex social determinants of health and ensure safe discharge planning.
• Provide crisis intervention and emotional support for patients and families during acute medical events, trauma, or end-of-life situations.
• Facilitate family meetings to clarify goals of care and address psychosocial concerns.
• Perform case management and resource navigation, including financial assistance, insurance benefits, transportation, and community programs.
• Advocate for patient rights and assist with advance directives and healthcare decision-making support.
• Ensure compliance with CMS Conditions of Participation for discharge planning and maintain HIPAA standards for confidentiality.
• Participate in interdisciplinary rounds and care conferences to communicate patient needs and advocate for appropriate services.
• Provide culturally competent care, respecting diversity and incorporating cultural values and family-centered practices.
• Document according to departmental standards and regulatory requirements to assure compliance and continuity of care.
• Participate in performance improvement activities, maintain educational records, and demonstrate competency.
• Attend departmental meetings, in-services, and assist with orientation of new personnel as assigned.

• Experience:
  
  N/A
• Education:
  
  Bachelors Degree in Social Work and two (2) years of social work experience in healthcare setting OR Masters Degree in Social Work.
• License, Certification, Registration:
  Licensed Bachelor Social Worker (Hawaii) OR Licensed Clinical Social Worker (Hawaii) OR Licensed Social Worker (Hawaii)
• Basic Life Support required at hire from American Heart Association

• Healthcare experience working with medical diagnoses.
• Demonstrated ability in networking with community agencies.

• Minimum one (1) year of social work experience.
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) Certification.

KAISER

CD Patient Care
- Continuing Care
- Medical Social Worker (BSW or MSW);
On-Call, MMMC

Wailuku, Hawaii

1424775

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.