Care Coordination Social Worker

CommonSpirit Health•Prescott, AZ

About The Position

The Social Worker performs social work assessments and interventions for hospitalized and emergency department patients. The role includes psychosocial assessments, crisis and patient/family interventions, high-risk screening, brief counseling, referrals for financial and other resource needs, arranging patient/family representative meetings with the healthcare team, and coordinating post-acute placement for complex discharges and appropriate agency or community-resource involvement for high-risk patients. The Social Worker provides developmentally appropriate care across patient populations, plans for safe discharge and continuity of care, and recognizes and plans for the needs of patients of all ages, including people who are physically disabled, mentally ill, chronically ill, terminally ill, or otherwise vulnerable. The position also supports patient and family advocacy and education, self-care and health-management education, bioethics referrals and management, and education for physicians, staff, and the community on case management and care coordination. The role coordinates community resources, provides life-care planning and consultation on healthcare resource management, and educates teams and patients about health-related insurance and support programs such as CCS, Medicare, Medicaid, and SSI. It also builds and maintains community relationships to address the needs of patients experiencing homelessness and other social determinants of health.

Requirements

Master of Social Work degree.
Arizona Master Social Worker credential (MSW:AZ).
One year of post-MSW experience or a social work internship in a clinical or medical setting.
Exceptional interpersonal skills, empathy, knowledge of community resources, and crisis-management abilities.

Nice To Haves

Three years of post-MSW healthcare experience.

Responsibilities

Conduct social work and psychosocial assessments for hospitalized and emergency department patients.
Provide crisis intervention, patient and family interventions, high-risk screening, and brief counseling.
Refer patients for financial assistance and other identified resources.
Arrange and facilitate meetings between patients or family representatives and the healthcare 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, accounting for the needs of patients across ages and circumstances, including disability, mental illness, chronic illness, terminal illness, and vulnerability.
Support patient and family self-care management and health-management education.
Coordinate bioethics referrals and management.
Provide education to physicians, staff, and community members on case management and care coordination.
Identify risk-management concerns and make referrals.
Provide life-care planning and expert consultation on healthcare resource management.
Educate patients and care teams about health-related insurance and support programs, including CCS, Medicare, Medicaid, and SSI.
Build and maintain community relationships to address needs related to homelessness and other social determinants of health.