Care Coordination Master Social Worker

CommonSpirit Health•Gig Harbor, WA

About The Position

Where You’ll Work Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area. Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person – body, mind, and spirit – in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth. Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care. We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose. Job Summary and Responsibilities Sign on bonus available! As our Social Worker, you will be a compassionate advocate, providing vital support and guidance to individuals and families facing complex challenges. Every day, you will conduct psychosocial assessments, develop care plans, provide counseling and crisis intervention, and connect clients to resources. You'll advocate for clients and collaborate with multidisciplinary teams to ensure holistic support and promote well-being. To be successful in this role, you will possess exceptional interpersonal skills, empathy, strong knowledge of community resources, and proven crisis management abilities, fostering positive change and client empowerment. Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients. Advocacy and education: patient/family self-care management; patient/family health management education; bioethics referrals and management; physician, staff, and community education; case/care management/coordination education and training; risk management identification and referral. Psychosocial management: crisis intervention; psychosocial assessment/functioning; counseling support and referral; abuse/neglect/trafficking identification, assessment, and referral (partner, child, elder, etc.); family issues affecting care; coping/emotional adjustment; grief/bereavement support (individual and group); adoption, surrogacy, and safe surrender support, management, and resources; health/wellness promotion; substance abuse screening, management, and resources; psychiatric screening, management, and resources; staff support; assessing, addressing, managing, and resources related to social determinants of health (e.g. housing and food insecurity, transportation). Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management. Continuity/Transition Management: As part of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to clinical social work scope of service and functions and social worker discretion; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; grave disability, palliative care/end-of-life, and hospice patient/family support, referrals, and management; interventions, management, and coordination of transition planning for psychosocially complex cases. Community Resource Coordination: life-care planning; expert consultation on health care resource management; team and patient education regarding various health-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social determinants of health needs.

Requirements

Masters Other Social Work and 1-Year Post-MSW experience or Social Work internship in a clinical or medical setting., upon hire
Licensed Independent Clinical Social Worker: WA, upon hire or Licensed Advanced Social Worker: WA, upon hire or Licensed Social Worker Associate Advanced:WA, upon hire or Master Social Worker: WA, upon hire

Nice To Haves

Minimum 3-Year Post-MSW healthcare experience

Responsibilities

conduct psychosocial assessments
develop care plans
provide counseling and crisis intervention
connect clients to resources
advocate for clients
collaborate with multidisciplinary teams to ensure holistic support and promote well-being
Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients.
Advocacy and education: patient/family self-care management; patient/family health management education; bioethics referrals and management; physician, staff, and community education; case/care management/coordination education and training; risk management identification and referral.
Psychosocial management: crisis intervention; psychosocial assessment/functioning; counseling support and referral; abuse/neglect/trafficking identification, assessment, and referral (partner, child, elder, etc.); family issues affecting care; coping/emotional adjustment; grief/bereavement support (individual and group); adoption, surrogacy, and safe surrender support, management, and resources; health/wellness promotion; substance abuse screening, management, and resources; psychiatric screening, management, and resources; staff support; assessing, addressing, managing, and resources related to social determinants of health (e.g. housing and food insecurity, transportation).
Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management.
Continuity/Transition Management: As part of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to clinical social work scope of service and functions and social worker discretion; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; grave disability, palliative care/end-of-life, and hospice patient/family support, referrals, and management; interventions, management, and coordination of transition planning for psychosocially complex cases.
Community Resource Coordination: life-care planning; expert consultation on health care resource management; team and patient education regarding various health-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social determinants of health needs.