- The social worker is a master’s prepared practitioner who possesses a comprehensive knowledge base established within a sound social work framework. The social worker provides direct and indirect care to a specific patient population using advanced social work assessment and supportive and counseling intervention skills, specialty expertise and age-appropriate interventions to facilitate appropriate use of healthcare resources and adjustment to illness. The social worker manages patients across the health care continuum to achieve optimal clinical, financial, operational and satisfaction outcomes and facilitates timely discharge planning. The social worker promotes interdisciplinary collaboration in all aspects of work, promotes staff and patient education and supports research. The social worker identifies opportunity for process improvement in all aspects of work.
- Member of Ethics Committee.
- Manages difficult patient placements for LTAC, nursing homes, transfers, etc.
- The evaluation is to assure individual performance, departmental goals and organizational goals are aligned. It is designed to support communication between the manager and the employee. Employee perception of their own performance is very important. To maximize the benefit of this process, both the manager and the employee participate in the evaluation process.
- Needs Improvement – Performance is consistently below requirements/expectations. Immediate improvement is necessary.
- Excellent customer service skills.
- Reads and understands the English language.
- Ability to think critically and analytically with little or no supervision
- Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes.
- Ability to process information and prioritize
- Possesses exceptional verbal and written communication skills
- Possesses independent work habits, is self-reliant and self-directed
- Ability to learn, adapt, and change as required by the job functions
- Ability to maintain absolute confidentiality of material and information accessed and reviewed
- Basic computer literacy
- Ability to move freely, reach, bend, and complete light lifting
- Ability to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelines
- Ability to maintain attendance to meet standard job practices
- Master’s degree in social work.
- MSW
- Minimum of three years in a broad range of human resources delivery management and practice.
- Recent clinical expertise in specific area (required for specialty clinical groups/clusters, preferred for others).
- Minimum two years relevant clinical experience preferred.
- Proven leadership and organizational skills preferred.
- Basic understanding of Medicare/Medicaid, insurance and regulatory guidelines (Rehab, Skilled) preferred.
- Possess the knowledge in medical and allied health sciences to apply criteria to the medical record with respect to patients needs for medical and health care.
- Be knowledgeable about medical terminology, levels of care, treatment modalities, and the present health care system, both hospital and community based.
- Effective communication skills.
- Working knowledge of DFCS system and APS.
- Sedentary: Exert up to 10 lb. of force occasionally and/or a minute amount frequently - greater than 75%
- Proven leadership and organizational skills preferred.
- Basic understanding of Medicare/Medicaid, insurance and regulatory guidelines (Rehab, Skilled) preferred.
- Possess the knowledge in medical and allied health sciences to apply criteria to the medical record with respect to patients needs for medical and health care.
- Knowledge of medical terminology, levels of care, treatment modalities, and the present health care system, both hospital and community based.
- Effective communication skills.
- Working knowledge of DFCS system and APS.
- Level II
- Neonates 1 - 30 days
- Infants 30 days - 1 year
- Children 1 - 12 years
- Adolescents 13 - 18 years
- Adults 19 - 70 years
- Geriatrics - 70+ years
- Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. Following are the essential functions of the position, along with the corresponding performance standards.
- Assessment
- Intervention
- Collaborates effectively with interdisciplinary team members to identify plan of care per LOS guidelines and evidenced based practice, including specific treatment goals and outcomes and consideration of efficacy, cost, safety and potential compliance
- Identifies inpatient/community resources to meet current and continuing care needs and coordinates referrals/authorizations/services for timely, effective service delivery
- Provides patient/family/significant other with education related to discharge options, admission criteria for services required, and application process for entitlement programs
- Implements patient specific discharge plan
- Communicates potential payer issues in a timely manner.
- Monitors patient progress: conducts ongoing assessment, reassessment to assure patient meets goals; manages variances to plan, revising goals/outcomes as necessary while assuring appropriate resource utilization
- Advocates for patient/family needs assisting the health care team in understanding patient needs/wishes and supports patient's right to self-determination
- Refers nursing home placement to the Placement Coordinator for follow-up
- Communicates plan and necessary medical information across the continuum to assure continuity of care
- Appraises manager of potential problems impacting plan and LOS associated with patient/family problems, placement issues and/or referral process to community agencies, transportation requests and legal issues
- Maintains ongoing communication with health care team regarding patient issues/plan and progress
- Documents psychosocial assessment and plan within 24 hours of referral/high risk screening and documents progress at minimum every three days or when there is significant change in patient status.
- Documents final disposition note to include confirmation of plan. If referred to community agencies will document distribution of the choice list as appropriate; referrals; confirmation of final discharge plan; distribution of the Important Notice from Medicare as appropriate; and agency/facility name/level of care/mode of transportation.
- Forms helping relationships with patient/family/significant others engages them in treatment
- Develops and maintains positive relationships with the health care team and with community agencies
- Pursues on-going professional development by attending relevant seminars and conferences
- Maintains current knowledge of social work and case management practice and issues affecting hospitals via literature, membership in professional organizations, peer consultation etc.
- Maintains requirements for licensure by the State Board of Social Work Examiners and/or professional organizations
Professional Field
Counseling
Nursing
Social Work
Other Behavioral, Mental, or Healthcare FieldPatient Focus
Diagnoses
Avoidant Personality Disorder
Issues
Stress
Age Groups
Children (5-10)
Preteens/Tweens (11-13)
Adolescents/Teenagers (14-19)
Adults
Elderly (65+)
Therapeutic Approach
Methodologies
ECT
Modalities
Families
Individuals
Practice Specifics
Populations
Victims of Crime/Abuse (VOC/VOA)
Aviation/Transportation
Racial Justice Allied
Settings
In-patient Non-Psychiatric
In-patient Psychiatric
Milieu
Private Practice
Research Facilities/Labs/Clinical Trials
Residential Treatment Facilities (RTC)
Schools
Substance Abuse Treatment Facilities
Home Health/In-home
Forensic



