Care Coordination Master Social Worker

CommonSpirit Health•Lakewood, WA

About The Position

The Care Coordination Master Social Worker provides compassionate support and guidance to individuals and families facing complex challenges. The role conducts psychosocial assessments, develops care plans, provides counseling and crisis intervention, connects clients with resources, advocates for clients, and collaborates with multidisciplinary teams to promote holistic support and well-being. Care is developmentally appropriate for people of all ages and accounts for the needs of patients who are physically disabled, mentally ill, chronically ill, terminally ill, or otherwise vulnerable. The social worker supports safe discharge and continuity of care; patient and family education and self-care management; bioethics and risk-management referrals; psychosocial assessment and counseling; crisis intervention; identification and referral for abuse, neglect, or trafficking; grief and bereavement support; substance-use and psychiatric screening and resource coordination; and support related to social determinants of health such as housing, food, and transportation. The role also participates in interdisciplinary care conferences and coordinates care transitions, post-acute care decisions, community resources, mental health services, and support for palliative, end-of-life, and hospice care. Community coordination includes life-care planning, consultation on healthcare resources, education about insurance and support programs, and relationship-building to address homelessness and other social needs.

Requirements

Master’s degree in Social Work.
One year of post-MSW experience or a Social Work internship in a clinical or medical setting.
Upon hire, one of the following Washington credentials: Licensed Independent Clinical Social Worker (LICSW), Licensed Advanced Social Worker (LASW), Licensed Social Worker Associate Advanced, or Master Social Worker.

Nice To Haves

Minimum three years of post-MSW healthcare experience.

Responsibilities

Provide developmentally appropriate care and plan for safe discharge and continuity of care, recognizing the needs of patients across age groups and with disabilities, mental illness, chronic or terminal illness, or vulnerability.
Provide patient and family self-care and health-management education; make bioethics and risk-management referrals; and educate physicians, staff, and community members on relevant care-management topics.
Conduct psychosocial assessments and provide crisis intervention, counseling support, and referrals.
Identify, assess, and refer cases involving abuse, neglect, or trafficking, including partner, child, and elder concerns.
Address family issues affecting care, coping and emotional adjustment, grief and bereavement, adoption, surrogacy, and safe surrender needs.
Promote health and wellness and provide substance-use and psychiatric screening, management, and resource coordination.
Assess and address social determinants of health, including housing and food insecurity and transportation needs.
Provide staff support and facilitate interdisciplinary patient and family care conferences related to care continuity and transitions.
Facilitate patient decisions and communications regarding post-acute care as part of the Care Management/Coordination team.
Maintain current community-resource lists and educate patients and families about available resources.
Coordinate mental health services and provide support, referrals, and management for grave disability, palliative care, end-of-life, and hospice situations.
Coordinate transition planning and interventions for psychosocially complex cases.
Provide life-care planning and expert consultation on healthcare resource management.
Educate teams and patients about health-related insurance and support programs, including CCS, Medicare, Medicaid, and SSI.
Build and maintain community relationships to address the needs of patients experiencing homelessness and other social determinants of health.