Job Title: Medical Social Worker

Job Code: SW MED

Department: Primary Care

Division: Nursing

Salary Level: Exempt 1

Reports to: Primary Care DON

Last Revised: October 2021

Primary Function

The incumbent is responsible for all operational activities of the Social Services program. The incumbent is responsible for planning, organizing, directing, coordinating, and managing Social Services activities in order to assure meeting the needs of the client. The position also includes case management duties to assure clinically and financially responsible care. He/She maintains liaison with other departments, agencies, organizations, and community resources in determining appropriate resource utilization.

Job Description

• Incumbent serves as the principle advisor and consultant to the Primary Care staff on all matters pertaining to social work services.
• The incumbent provides a wide range of social work activities to eligible Primary Care patients.
• The incumbent carries clinical responsibility for Primary Care and acts as liaison with social work programs including state, BIA, community and Tribal social work activities.
• The incumbent is the official liaison between Primary Care and other social service and human service programs in the area, including Tribal, BIA, community, courts, and other medical facilities upon request for the Indian population served.
• Plans and provides direct social work services to Primary Care patients and their families on an individual or group basis.
• Services may include, but are not limited to, assisting patients and families cope socially and emotionally with physical disability and/or illness, discharge planning, arranging patient transfer and transporting to other facilities, financial planning, death and dying counseling, advanced directive counseling, referral to other resources, counseling services, and child abuse/neglect referrals. Provides needed services as determined from a developed plan of care and assessment.

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  Through consultation, shares social evaluations and knowledge of patients, their families, and community resources with physicians, planning for the treatment and/or rehabilitation of patients.
• Establishes and maintains liaison and close working relationships with county social services, related agencies and organizations in the service unit to secure services for American Indians on the same basis as for non-Indians.
• Attends conferences and meetings relating to social service practices.
• Develops an individual primary plan of care, assesses patients needs through interviews with patients, relatives, and others to obtain pertinent information.
• Responsible for establishing, implementing, and enforcing Social Services program policies and procedures and reviewing and revising existing policies and procedures at appropriate intervals.
• Insures conformance to acceptable standards of Social Service and Case Management practice, including all policies, procedures, rules, and regulations of the Cherokee Indian Hospital, JCAHO, CMS, and State Division of Medical Assistance.
• Responsible for planning, developing, and implementing the Social Service program. Directs Social Service activities within the organization including concurrent and retrospective reviews, identification of actual and/or potential delays in service and/or treatment, and reporting trends of inappropriate utilization of resources.
• Attends daily multidisciplinary inpatient rounds and confers with Inpatient Social Worker and Medical staff on Social Services and Case Management problems and develops and implements plans for corrective action.
• Will assist nursing staff as needed with coordination of care and disposition of patients from the Primary Care, such as, but not limited to patients requiring placement or transfer to mental health facilities and other facilities
• Utilizes the care management platform for documentation of interventions and outcomes and interactions with individuals encountered in providing care.
• Interprets patient’s resource and case management needs to the Medical and Nursing staff and collaborates with them in the determining available resources. Maintains communication with insurance providers in determining plan of care and coordinates care with the patient’s Integrated Care Team.
• Reviews Purchased and Referred Care referrals daily through the RPMS and maintains liaison with the referral organization to determine plan of care, anticipated discharge or transfer dates, and case management needs under the direction of the Primary Care Director of Nursing.
• Responsible for identifying providers or services needed to coordinate the patient’s care in the Primary Care setting, or upon discharge from the Cherokee Indian Hospital or regional facility.
• Maintains files and prepares reports on Social Service and Case Management activities and areas for improvement for submission to the Primary Care Nurse Manager and other appropriate groups.
• Maintains and promotes positive and constructive communications and activities within nursing services, other departments, tribal, and community agencies for purposes of coordinating and understanding of program goals.
• Participates in the development and implementation of Performance Improvement activities, and participates or leads at least one Quality Improvement activity per year (PDSA).
• Attends meetings, planning sessions, committees, and serves on teams to promote quality and performance improvement.
• Actively participates with the Integrated Care Teams in planning, organizing, and directing departmental services.
• Participates in various hospital committees as assigned.

Performs other related duties as required.

Education, Licensure, Certification, and Experience

• Bachelors Degree in Social Work.
• At least 2 years experience as a Social Worker. Prefer that experience reflects knowledge of Hospital Social Work.
• Current Basic Life Support (BLS) required for the position. Can be acquired through the facility following appointment to position.

Job Knowledge

• Knowledge of principles, practices, techniques, and theories of social work in order to plan and provide social services to meet the physical, emotional, spiritual, and socio cultural needs of patients of all ages; specifically, Infancy (Birth-1 year), Toddler and Early Childhood (2-5 years), Latency (6-9 years), Preadolescence (10-12 years), Early Adolescence (13-15 years), Adolescence (16-20), Adult (21-64 years), and Elderly (65-+ years).
• Knowledge of social services and its application to clinical practice.
• Knowledge of disease process, health care treatment and systems, and treatment protocols.
• Knowledge of health care financial management, provider payer mechanisms, business environment, and resource management.
• Knowledge of strategic planning, outcome measurement, quantitative methods and statistics.
• Knowledge of ICD_10 coding, billing practices.
• Knowledge and ability to analyze the results of various medical procedures and translate into appropriate plans of care.
• Knowledge of nursing home admission requirements, including steps to initiate nursing home processing.
• Knowledge of Family Care Services policy and procedures and ability to coordinate care requirements with patient centered goals in mind.
• Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations.
• Knowledge of the occupational functions of multi-disciplinary integrated health care teams.
• Knowledge of the culture and health profile of the patient population.
• Knowledge and ability to teach and counsel patient/family and staff on plans for care and use of health care resources.
• Knowledge of available health care programs and community resources.
• Knowledge of processes and procedures for establishing, revising, continually monitoring, and evaluating standards for Social Services.
• Knowledge of medical record documentation and how to perform medical record reviews.
• Ability to communicate to and interact with persons, (staff, health care professionals, individuals in the community) with different functions, levels of knowledge, and requirements.
• Knowledge of JCAHO accreditation standards, social services quality improvement standards, HCFA regulations, Medicare, Medicaid, and private insurance.
• Knowledge of clinical teaching methodologies and methods of evaluating the effectiveness of teaching strategies.
• Ability to gather and analyze data and communicate findings.

Complexity of Duties

Guidelines consist of professional standards of practice, medical policies and procedures. Must, also, comply with Compliance Plan, Utilization Review Plan, State and Federal guidelines, CMS, FPM, DHHS, PHS, and IHS regulations. These guidelines are not always specifically applicable to the individual patient or situation and independent judgment is required in selecting the most appropriate guideline, and applying the intent.

Requirements are complex in that they require comprehensive skills in Social Services and Case Management and have sufficient knowledge of medicine to evaluate patient care. This may involve difficult interactions with the clinical staff, case managers, care managers, and insurance payers and require maximum skills in diplomacy and judgment.

Supervision Received:

Incumbent receives administrative guidance from the Primary Care Nurse Manager. Works within the framework of regulations, policies, and procedures established by the agency, CMS, and North Carolina Division of Medical Assistance. Further guidance is received from Professional Literature, Indian Health Service Manuals, and Program Area Directives. Is expected to exercise a high degree of independent initiative and judgment in development and implementing new approaches to the delivery of quality care. Functions with a minimum of guidance and supervision. The Primary Care Nurse Manager sets the overall objectives and resources available.

Responsibility for Accuracy

The incumbent’s performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided. Evaluations and observations are used to modify and develop clinically and financially appropriate treatment plans. The incumbent has a positive effect upon the recovery of the patient and is responsible for the development of policies and procedures, which serve as hospital guidelines.