Job Description

Provides social work services to patients, families, and individuals including psychosocial assessment, screening, determination of needs evaluation, appropriate interventions and follow up, and discharge planning. Implements interventions substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources and payer network. Participates as part of the multi-disciplinary health care team to develop safe and timely coordination of care including but not limited to post-acute placement, palliative/hospice service lines, medical equipment, home healthcare, outpatient follow up, mental health resources, and other community resources. Advocates for patient involvement in the plan of care. Initiates and coordinates interventions with the activities of other members of the health care team. Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educating patients and families on these issues as appropriate. Provides resources to patients and families to ensure a timely discharge and to provide an appropriate link with post-acute care providers and services. Provides support and connection to additional services such as bereavement and loss, ethical issues, advanced directives, and end of life issues. Connects patients to appropriate agencies on issues of suspected abuse and neglect, domestic violence, guardianship, and other social matters. Collaborates with community agencies and institutions to plan continued care and to coordinate interventions Provides resources and education to patients and families regarding appropriate resources and access to community social services. Communicates effectively with patients, family, other members of the health care team and community agencies and facilitates resolution of issues which could impact on continuity of care (e.g., prior-approvals, application requirements, transfer paperwork). Documents activity according to department and program protocols or standards. Manages the progression of patients stay with the goal of optimizing the LOS and ensuring appropriateness of assigned Level of Care. Manages the patient’s care across the continuum to decrease unnecessary readmissions. Manages and coordinates patient care within an ACO environment to help facilitate patient outcomes through in network care coordination. Accountable for site specific KRA goal achievement as it relates to Care Coordination across the continuum. Participates in the orientation of new staff and/or education of social work students. Provides education to patients/families regarding Advance Directives for health care decision-making. Assists with execution of these documents as appropriate. Participates in legal proceedings as necessary to secure legal decision-makers. Maintains professional standards and responsibilities for his/her own professional practice according to accreditation, hospital, system, state and NASW Standards and Code of Ethics. Completes all required continuing education to maintain licensure and increase knowledge within area of practice specialty. This position requires travel, therefore, will be exposed to weather and road conditions. Operates all equipment necessary to perform the job. Exposed to a normal office environment. Exposed to patient care environment. May be exposed to hazardous materials and life-threatening diseases, therefore team members must abide by personal protective equipment as ordered. Weekend, holiday, and evening coverage per site requirement. Position requires sitting, standing, speaking, reading/writing, and walking throughout the workday. Fast paced work environment with established time constraints per site. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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