About Job
- 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 timeframes.
- Adheres to all hospital policies, standards of practice and Federal or State regulations pertaining to their practice.
- Performs other duties as assigned.
Professional Field



Patient Focus
Diagnoses
Avoidant Personality Disorder
Issues
Aging
Therapeutic Approach
Methodologies
ECT
Modalities
Families
Individuals
Practice Specifics
Populations
Hospice/Palliative Care
Victims of Crime/Abuse (VOC/VOA)
Aviation/Transportation
Racial Justice Allied
Settings
Hospice
In-patient Non-Psychiatric
In-patient Psychiatric
Partial Hospitalization (PHP)
Private Practice
Research Facilities/Labs/Clinical Trials
State/Federal Government
Home Health/In-home
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