Care Coordination Social Worker
About The Position
As a Social Worker, perform social work assessments and interventions for hospitalized and emergency department patients. The role includes psychosocial assessment, crisis and patient/family intervention, high-risk screening, brief counseling, and referrals for financial or other identified resource needs. Arrange and facilitate meetings between patients or family representatives and the healthcare team as needed, coordinate post-acute placement for complex discharges, and engage appropriate agencies or community resources when high-risk patients are identified. Provide developmentally appropriate care across the populations served. Plan for safe discharge and continuity of care, recognizing and planning for the needs of people of all ages, people with physical disabilities or mental illness, chronically or terminally ill patients, and vulnerable patients. Support advocacy and education, including patient and family self-care management and health-management education, bioethics referrals and management, education for physicians, staff, and the community, case/care management and coordination education and training, and identification and referral of risk-management concerns. Coordinate community resources through life-care planning, expert consultation on healthcare resource management, and education for teams and patients about health-related insurance and support programs such as CCS, Medicare, Medicaid, and SSI. Build and maintain community relationships to address the needs of patients experiencing homelessness and other social determinants of health.
Requirements
- Master's degree in Social Work.
- Master Social Worker: AZ (MSW:AZ).
- One year of post-MSW experience or a Social Work internship in a clinical or medical setting.
- Exceptional interpersonal skills, empathy, strong knowledge of community resources, and crisis-management abilities.
Nice To Haves
- Three years of post-MSW healthcare experience.
Responsibilities
- Conduct psychosocial assessments for hospitalized and emergency department patients.
- Provide crisis intervention, patient/family intervention, high-risk screening, and brief counseling.
- Refer patients for financial assistance or 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 diverse patient populations.
- Provide patient and family self-care management and health-management education.
- Manage bioethics referrals and provide education to physicians, staff, and the community.
- Provide case/care management and coordination education and training.
- Identify risk-management concerns and make referrals.
- 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 homelessness and other social determinants of health.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
