Care Coordination Social Worker MSW

CHI Saint Joseph Health System•Lexington, KY

3d•$27 - $40•Onsite

About The Position

This role is at Saint Joseph Hospital, a 433-bed hospital founded in 1877 and recognized as a 2024 Best Place to Work in Kentucky. Saint Joseph Hospital is part of CommonSpirit Health, a non-profit, Catholic health system dedicated to advancing health for all people. As a Care Coordination Social Worker MSW, you will drive patient well-being and resource navigation, directly impacting the holistic care and successful transitions for hospitalized and emergency department patients. You will serve as a critical member of the Care Coordination and multidisciplinary healthcare teams, ensuring comprehensive support and linkage to essential resources.

Requirements

Masters Other Social Work (MSW), upon hire
Licensed Social Worker: KY, upon hire
Master Social Worker: KY, upon hire

Nice To Haves

One year of healthcare experience

Responsibilities

Performing social work screenings and interventions for hospitalized and emergency department patients, in consultation with as needed and collaboratively with the Care Coordination and multidisciplinary healthcare teams.
Providing patient/family support and making appropriate referrals.
Conducting thorough social needs screenings.
Facilitating referrals for financial or other identified resource needs.
Arranging family/patient representative meetings with the healthcare team as needed.
Assisting in the post-acute placement of complex discharges.
Engaging appropriate agencies or community resources when patient's social needs are identified.
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 support; patient/family health management education; healthcare team and community education; case/care management/coordination education and training; social needs identification and referral.
Complex social needs management: social needs screenings; determination of patient functioning and availability of support systems; support in addressing social needs and making related referrals; escalation of identified cases involving abuse, neglect, trafficking, complex family issues affecting care, grief/bereavement support (individual and group), adoptions, surrogacy, safe surrender, substance use and abuse, and significant mental health or psychiatric concerns; addressing, managing, and referring 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; share in responsibility for identifying appropriate decision makers if the patient is unable or without capacity.
Discharge/Transition Management: as member of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to social work scope of practice; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; assistance in referral and management of grave disability, palliative care/end-of-life, and hospice patient/family needs; interventions, management, and coordination of discharge/transition planning for socially complex cases.
Community Resource Coordination: life-care planning; consultation on healthcare resources; team and patient education regarding various healthcare-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 needs.