Care Coordination Master Social Worker

Memorial Hospital - Chattanooga•Ringgold, GA

23h•$25 - $38

About The Position

The Social Worker performs social work assessments and interventions for hospitalized and emergency department patients. The role includes crisis and patient/family intervention, high-risk screening, brief counseling, referrals for financial and other identified resource needs, arranging patient or family representative meetings with the health care team, coordinating post-acute placement for complex discharges, and engaging appropriate agencies and community resources for high-risk patients. As part of the Care Management/Coordination team, the Social Worker supports safe discharge and continuity of care for patients across age groups and with varied physical, mental, chronic, terminal, and other vulnerabilities. The role includes psychosocial support and counseling, advocacy and education, care conference coordination, transition planning, community resource coordination, and contributions to performance and outcomes management. The Social Worker may also support outpatients when directed by Care Coordination leaders, participate in performance improvement activities, complete required education, and comply with organizational policies and applicable regulations.

Requirements

Master’s degree from a school of social work accredited by the Council of Social Work Education.
One year of post-MSW experience or a social work internship in a clinical or medical setting.
Initial social work licensure or higher, as required by state law.
Excellent customer service and presentation skills.
Strong interpersonal and written communication skills.
Demonstrated ability to apply analytical and problem-solving skills.
Demonstrated ability to manage multiple tasks or projects effectively.
Ability to work independently as needed with a high degree of detail orientation.
Ability to work efficiently in a fast-paced environment with changing priorities.
Ability to work collaboratively with an interdisciplinary care team.

Responsibilities

Perform social work assessments and interventions for hospitalized and emergency department patients.
Provide crisis intervention, patient and family intervention, high-risk screening, brief counseling, and referrals for financial or other resource needs.
Arrange and facilitate patient or family representative meetings with the health care team as needed.
Arrange post-acute placement for complex discharges and engage appropriate agencies or community resources for high-risk patients.
Plan for safe discharge and continuity of care, recognizing and addressing the needs of patients of all ages and patients with disabilities, mental illness, chronic illness, terminal illness, or other vulnerabilities.
Provide advocacy and education related to patient and family self-care, health management, bioethics, case and care management, and risk management.
Provide psychosocial assessment, counseling, crisis support, and referrals; identify and address abuse, neglect, trafficking, family issues, coping and emotional adjustment, grief, substance use, psychiatric needs, and social determinants of health.
Support patients and families with adoption, surrogacy, safe surrender, health and wellness promotion, and staff support needs.
Coordinate interdisciplinary patient and family care conferences concerning continuity and transitions of care.
Facilitate patient decisions and communications regarding post-acute care and coordinate transition planning for psychosocially complex cases.
Maintain current community resource lists and educate patients and families about available resources.
Coordinate mental health services and provide support, referrals, and management related to grave disability, palliative care, end-of-life care, and hospice.
Coordinate community resources and provide consultation on health care resource management, life-care planning, and health-related insurance and support programs such as CCS, Medicare, Medicaid, and SSI.
Build and maintain community relationships to address homelessness and other social determinants of health.
Apply regulatory and accreditation requirements and evidence-based practices, and support organizational financial performance, length of stay, cost per case, readmission prevention, and revenue cycle goals.
Provide outpatient social work services when directed by Care Coordination leaders.
Participate in performance improvement teams and programs as necessary.
Demonstrate behavior aligned with the organization's mission and core values.
Complete required education within established timeframes and adhere to hospital policies, standards of practice, and applicable federal and state regulations.
Perform other duties as assigned.