JOB DESCRIPTION

The Palliative Care Social Worker is responsible for facilitating and supporting the care of patients with serious, life-limiting illnesses across both inpatient and outpatient settings. This role focuses on care coordination, discharge planning, and ensuring patients receive appropriate support services.

RESPONSIBILITIES

• Conduct psychosocial assessments to identify patient needs and develop appropriate care plans.
• Assist in identifying patients appropriate for palliative care services and initiate referrals in collaboration with the medical team.
• Coordinate palliative care consults by communicating with providers, patients, and families.
• Collaborate with physicians, nurses, and other healthcare professionals to ensure coordinated and comprehensive patient care.
• Participate in interdisciplinary team meetings and contribute to care discussions and decision-making processes.
• Assist patients and families with discharge planning, including arranging for home care services, rehabilitation, referrals to hospice, or other necessary follow-up care.
• Advocate for patients’ needs and preferences, ensuring their voices are heard and their care preferences are respected.
• Address any issues related to patient rights, access to care, or ethical considerations in collaboration with the care team and hospital leadership.
• Coordinate with community resources and agencies to provide patients with additional support.
• Serve as a liaison between patients, families, and the healthcare team, addressing any concerns or questions related to care and treatment. Provide guidance and support to patients and families regarding care options, resources, and follow-up plans.
• Educate patients and families on coping strategies, treatment adherence, and navigating the transplant process.
• Develop and implement support groups or educational programs for patients and families.
• Support advance care planning discussions and assist with documenting patients’ goals of care and treatment preferences.
• Provide patient- and family-centered counseling to address coping with serious illness, caregiver strain, anticipatory grief, and end-of-life concerns.
• Track palliative care referrals, outcomes, and follow-ups to contribute to program evaluation and improvement.
• Monitor patient progress and adjust care plans as necessary to achieve optimal health outcomes.
• Document patient assessments, care plans, and progress notes accurately and in a timely manner.
• Maintain accurate and confidential patient records and documentation.
  
  

QUALIFICATIONS

• Ability to work effectively as part of an interdisciplinary healthcare team.
• Ability to advocate for patients and navigate complex healthcare systems.
• Strong assessment and problem-solving skills.
• Ability to work collaboratively and flexibly with a diverse team
• Ability to coordinate, analyze, observe, make decisions, and meet deadlines in a detail-oriented manner
• Ability to provide empathetic and non-judgmental support to patients and families.
• Thorough understanding of medical terminology and hospital procedures.
• Familiarity with community resources, support services, and public assistance programs.
• Ability to manage multiple priorities, effective organizational and time management skills, along with strong teamwork skills.
• Demonstrated proficiency in the use of Electronic Medical Record and Case Management software.
• Effective computer skills using Microsoft Office (Word, Excel, PowerPoint, etc.) and database software.
  
  

Education:

• Master’s Degree in Social Work or Bachelors in Nursing required
  
  

Experience:

• Minimum of two (2) years of experience in a hospital or acute care setting
• Minimum of two (2) years of experience in a palliative care/hospice preferred
  
  

Licenses And Certifications:

• LMSW or RN license required upon hire.
• LCSW strongly preferred
  
  

REQUIRED SKILLS

Minimum of 2 years of experience in a hospital or acute care setting

REQUIRED SKILLS

Minimum of two (2) years of experience in a palliative care/hospice preferred