About Job

Job Summary:

Provides patients and families with the psychosocial support needed to cope with chronic, acute, or terminal illnesses. Services include advising family care givers, providing patient education and counseling, and making referrals for other services. May also provide care and case management or interventions designed to promote health, prevent disease, and address barriers to access to healthcare.

Job Description:

Delivers professional and thorough social work services, including psychosocial assessment and intervention planning.
Identifies patients who require social work assessment and intervention through high risk screening, interdisciplinary team meetings and individual referrals.
Conducts assessments that address bio-psycho-social issues for age, population and health specific needs which results in individualized plans of care.
Provides support and counseling to patients and families.
Provides information and assistance for identified financial or social needs.
Coordinates complex transition plans with patients, families, health care team and community providers.
Utilizes the electronic medical record to monitor, document and communicate patient progress toward goals and progression of the social work plan.
Collaborates and communicates with interdisciplinary team anticipating needs to move the plan of care forward.
Provides support and information to patient and families regarding transition plan.
Maintains knowledge of government and private payer networks and services to assure appropriate transitions.
Collaborates with community and health care resources based on need to coordinate care for the patient.
Advocates for patients and families by supporting patient rights and accessing protective services.
Demonstrates awareness of patient rights and ethical decision making; provides advocacy to support patient and family.
Assures appropriate reporting of vulnerability or suspected abuse as mandated by law.
May participate in care system process that prevent readmissions.
Plans and participates in transition conferences with patients and families.
Utilizes tools and technology to identify and intervene with patients who are at risk for readmission.
Ensures that a complete clinical handoff occurs for at risk patient, which may include referrals.
May collaborate with the health care team to promote appropriate length of stay.
Utilizes tools and technology to support appropriate length of stay management.
Facilitates timely referrals and transfers of information.
Other duties as assigned.