Social Worker MSW

Description:

JOB PURPOSE:
This position strives to promote patient and family wellness, improved care outcomes, access to appropriate hospital and community resources, and manages, supports and develops comprehensive transitional care plans for patients with complex and psychosocial needs in Inpatient and Emergency Department (ED) environments. Works to promote quality of care and effective transitions planning through collaboration with all service team members, physicians, patients, external agencies and families.

KEY RESPONSIBILITIES:
1. Assesses, evaluates, plans and coordinates community services
2. Advocates for services to meet the specific patients / family complex needs
3. Conducts high risk assessments within timeline required by departmental and regulatory guidelines
4. Coordinates with Care Manager daily
5. Conducts psychosocial assessments
6. Provides patients / family members with Community Resources
7. Coordinates the transition to post-acute care services (Hospice, Home Health, Skilled Nursing Facility, etc.)
8. Coordinates as needed with other members of the care team
9. Works with the treatment team to provide solutions for complex cases (i.e. Behavioral Health and/or barriers to discharge)
10. Identifies high risk patients based on standardized criteria
11. Coordinates appropriate reporting to legal agencies as needed with respect to abuse and neglect
12. Facilitates the coordination of financial assistance as needed
13. Identifies and documents quality variances and/or barriers to discharge
14. Provides post discharge follow-up as appropriate to ensure continuity of care/services
15. Participates in PHC readmission management initiatives

MINIMUM EDUCATION REQUIRED:
Masters degree in Social Work from an accredited social work program is required.

MINIMUM EXPERIENCE REQUIRED:
none.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:
none.

ADDITIONAL QUALIFICATIONS:
ACM, CCM, LMSW preferred.