About Job
- Coordinates, facilitates, and executes Social Work functions with the patient population through effective collaboration and communication with the Interdisciplinary Care Transitions (ICT) team members
- Follows patients throughout the care continuum, identifying and addressing psychosocial needs
- Provides ongoing support and expertise through specialized application of assessment, individual treatment plans, continuous evaluation of treatment planning, case management, mediation, referral, consultation, education, and advocacy
- Enhances the quality of patient management and satisfaction to promote continuity of care through the integration of the functions of case management, discharge planning, and the application of social work practices
- Acts as a patient advocate, investigates and reports adverse occurrences, performs staff education related to discharge planning and psychosocial aspects of healthcare delivery
- Advocates for the understanding of significant physical, biological, psychological, emotional, and environmental factors underlying patient's health issues
- Coordinates psychosocial activities with the Interdisciplinary Team and Physicians to provide comprehensive discharge planning
- Utilizes critical thinking to develop and execute effective discharge plans
- Conducts comprehensive, ongoing biopsychosocial assessments of patients and families
- Serves as a patient advocate and fosters collaborative relationships to support informed decision-making
- Participates in interdisciplinary patient care rounds and/or conferences
- Provides patient and family education on post-hospital needs
- Collaborates with clinical staff on the development and implementation of care plans
- Educates patients, families, and the healthcare team on cultural, ethical, abuse/neglect, and financial matters
- Refers patients and families to appropriate community resources
- Applies knowledge of growth and development to provide age-appropriate support
- Coordinates social services to support family functioning and healthcare utilization
- Serves on division and hospital committees as needed
- Arranges for post-hospital care through community institutions and agencies
- Knowledge of payor practices, regulations, and reimbursement related to discharge planning
- Familiarity with Medicare benefits, insurance processes, and contracts
- Understanding of accreditation standards and compliance requirements
- Proficiency in English; strong verbal and written communication skills
- Strong critical thinking, prioritization, and time management skills
- Basic computer skills, including Microsoft Office
- Effective interpersonal skills with patients, families, and staff
- Regular attendance required
- Travel requirement: Approximately 0%
- Stand: Occasionally
- Walk: Occasionally
- Sit: Constantly
- See, talk, and hear: Constantly
- Finger, handle, or feel: Constantly
- Push/Pull: Occasionally
- Stoop, kneel, crouch, or crawl: Occasionally
- Reach with hands and arms: Occasionally
- Taste or smell: None
- Lift up to 10 pounds: Frequently
- Lift up to 20 pounds: Occasionally
- Lift more than 20 pounds: Not required
- Vision requirements: Close vision, distance vision, color vision, peripheral vision, depth perception, ability to adjust focus
- Hearing requirements: Ability to hear alarms, client calls, and instructions
- Exposure to blood, body fluids, or tissues: None
- Exposure to latex: None
- Exposure to fumes, airborne particles, toxic or caustic chemicals: None
- Exposure to outdoor weather, extreme heat/cold, or wet conditions: None
- Risk of electrical shock, radiation, vibration, or loud noise: None
- Exposure to moving mechanical parts: None
- Graduate of an accredited program in Social Work, Psychology, or a related field
- Master of Social Work preferred
- Social Work License required
- Certification in Case Management preferred
- Three years of experience in a healthcare setting preferred
- Experience in case management or discharge planning preferred
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